Columbia  (Bnttimftp 
mtlieCttpofl^mjgark 

College  of  l^f^p^itim^  anb  burgeons; 
Hihvaxp 


5 


v6-r' 


V 


LP  ^ 


SURGERY    FOR    DENTAL 

AND 

JUNIOR    MEDICAL   STUDENTS. 


A  Handbook  on  Surgery 


INTENDED      FOR 


DENTAL    AND     JUNIOR     MEDICAL 
STUDENTS 


ARTHUR    S.   UNDERWOOD,   M.R.C.S.Eng..   L.D.S.Enc, 

late  Examiner   Royal  College  of  Surgeons  of  England,  &c.,  &c., 

AND 

BAYFORD    UNDERWOOD,   M.B.,   B.S.Lond.,  L.R.C.P.. 
M.R.C.S.Eng. 


NEW    YORK 

WILLIAM     WOOD     &     COMPANY 

MDCCCCXIII 


R2>3/ 


cr> 


^  PREFACE. 

s  


TiiK  authors  of  the  present  handbook  have  long-  feh 

that,    considering    the   circumscribed    field    of    general 

surgery    that    is    required   of    dental    students    by    the 

licensing    bodies,    the    existing    textbooks    should    be 

supplemented  by   one   treating   this    subject    from    the 

point  of  view  of  the  requirements  of  the  examinations 

for  the  dental  licence.     They  have  also  hoped  that  a 

clearly-written  elementary  treatise  might  not  be  unwel- 

comed  by  the  general  student  as  an  introduction  to  the 

study    of     Surgery.     Ten     years'     experience     as     an 

Z  examiner    on    the    English    board     seemed     a    fitting 

qualification  for  the  preparation  of  such  a  work,   and 

^a  visit  of  inspection  as  emissary  of  the  General  Medical 

^  Council  to  all  the  existing  British  examinations  has,  it 

^is  hoped,  prevented  a  narrow  or  local  purview  of  the 

subject.     The   important   question  of   Anaesthesia   has 

!!!;^een  entirely  omitted  for  the  sufficient  reason  that  most 

excellent  and   accessible   handbooks   dealing  with  this 

subject  have  already  been  written  by  professed  experts. 

)      Free  use  has  been  made   of  current  standard  text- 

^books,  and  the  authors  wish  to  express  their  indebted- 

Npess  most  particularly  to  the  authors   of   "  Rose   and 

'  Carless's  Surgery,"  "  Thomson  and  Miles's  Surgery," 

and  "  Waring's  Operative  Surgery." 

A.  S.  U., 

A.  B.  G.  U. 

.^        26,  Wimpole  Street,  W. 

\ 


ERRATUM. 


P.  71,  line  I ^,  for  ''  mtj.ns  of  sterilized  milk"  ;rc?c/ '' means  of 
sterilized  silk.'' 


CONTENTS. 


CHAPTER  I.  PAGE 

Bacteriology       i 

CHAPTER  II. 

ASKPSIS    AND    AXTISF.rSIS  II 

CHAPTER  III. 

L\FLAM.MATIO.\         l8 

CHAPTER  IV. 
Ulceration  "      ...      26 

CHAPTER  V. 
Gangrene  31 

CHAPTER  VI. 
Wounds  2)7 

CHAPTER  VII. 
H.i-:-M0rrhage       51 

CHAPTER  VIII. 
Diseases  of  Arteries  and  A^eins     55 

CHAPTER  IX. 
Injuries  and  Diseases  of  Nerves 61 

CHAPTER  X. 
Diseases  of  the  Lymfhatic  System 70 

CHAPTER  XI. 
Diseases  of  Ductless  Glands        75 

CHAPTER  XII. 
Si'EciFic  Infective  Diseases Si 

CHAPTER    XIII. 
General  Constitutional  Diseases 102 

CHAPTER    XIV. 
New  Growths  ^Solid 106 


Vlll  COXrKXTS 

CHAPTER    XV.  PAGE 

Cysts  ii6 

CHAPTER    XVL 
Injuries  of  Bone  ...,       "9 

CHAPTER    XVn. 
Diseases  ok  Boxe        130 

CHAPTER  XVIII. 
Injuries  of  Joints        139 

CHAPTER  XIX. 
Diseases  of  Joints       152 

CHAPTER  XX. 
SrEciAL  Injuries  of  Face  and  Xeck  162 

CHAPTER  XXI. 

Diseases  of  the  Mouth,   Lips,   Palate,   Tonsils,   and 

Pharynx        167 

CHAPTER  XXII. 
Diseases  of  the  Tongue       i(S2 

CHAPTER  XXIII. 
Diseases  of  the  Gums  and  Jaws    1S8 

CHAPTER  XXIV. 
Diseases  of  the  Xose  ig4 

CHAPTER   XXV. 
Diseases  of  the  Accessory  Sinuses         iqo 

CHAPTER  XXVI. 
Diseases  of  the  Salivary  Glands 204 

CHAPTER  XXVII. 
Diseases  of  the  Larynx        206 

CHAPTER   XXVIII. 
Cert.ain  Diseases  of  Neck 208 

CHAPTER   XXIX. 
Diseases  of  the  Eye 211 

CHAPTER   XXX. 
Diseases  of  the  Skin 221 

Index         226 


SURGERY  FOR  DENTAL  AND  JUNIOR 
MEDICAL   STUDENTS. 


CHAPTER    I. 
BACTERIOLOGY. 


As  an  introduction  to  the  study  of  surgery,  some 
acquaintance  with  the  nature  and  behaviour  of  bacteria 
is  of  great  importance.  Practically  the  whole  of 
modern  surgical  treatment,  and,  to  a  great  extent, 
diagnosis,  rests  upon  a  knowledge  of  the  bacterial 
processes  involved. 

Bacteria  or  Schizomycetes  are  a  group  of  unicellular 
organisms  containing  no  chlorophyll  and  reproducing 
themselves  in  most  cases  by  simple  fission.  They  vary 
considerably  in  shape  and  size,  some  being  as  small 
as  .5  M  in  diameter,  that  is,  about  one-fifteenth  the  size 
of  a  red  blood  corpuscle;  while  others  may  be  6  or  7  ^ 
in  length.  They  are  rarely  larger  than  the  diameter 
of  a  red  blood  cell  (7.5  ^).  Some  are  possessed  of 
thread-like  processes,  called  flagella,  by  the  vibration 
of  which  they  are  enabled  to  move  about. 

Many  a  stern  battle  has  been  wag'ed  over  the  question 
as  to  whether  these  organisms  should  be  classed  as 
animal  or  vegetable;  at  the  present  moment  their 
position  as  plants  of  the  class  fungi  seems  to  be  secure. 

Reproduction  takes  place  in  two  ways,  both  of  which 
are  entirely  asexual.  The  first,  and  by  far  the  most 
common,  method  is  simple  fission.  A  constriction 
appears  at  about  the  middle  of  the  organism  and 
gradually  increases  in  depth  until  the  cell  becomes 
completely  divided  into  two.  No  more  complicated 
method  of  division  such  as  karyokinesis  has  been 
described  among  this  class. 

The  second  method  of  reproduction  is  by  formation 
of  spores.     This  is  only  found  in  a  few  forms,  notably 
1 


2  SURGERY    FOR    DENTAL     STUDENTS 

in  the  organisms  of  tetanus,  anthrax,  and  malignant 
oedema.  At  first,  Httle,  highly  refractile  granules,  often 
described  as  "  like  oily-looking  droplets,"  make  their 
appearance  in  the  protoplasm  of  the  organism.  These 
granules  join,  or  rather  flow  together  to  form  one 
large  granule,  which  is  the  spore.  The  fully  formed 
spore  consists  of  protoplasm,  rather  poorer  in  water 
than  normal  protoplasm,  surrounded  by  a  thick  cell- 
wall.  Spores  are  very  much  more  resistant  than  the 
bacteria  from  which  they  arise;  indeed,  they  are 
specially  adapted  to  preserve  the  species  under  condi- 
tions which  to  the  less  resistant  bacteria  would  prove 
fatal. 

An  extremely  large  number  of  species  has  been 
described  at  one  time  or  another,  but,  fortunately  for 
the  student,  comparatively  few  are  of  surgical  import- 
ance. 


Fig.  I. — Streptococci.  Fig.  2. — Diplococci. 

Bacteria  are  divided,  according  to  their  shape,  into 
three  great  classes. 

(1)  Cocci. — These  organisms  are  spherical  in  shape, 
or  nearly  so;  they  reproduce  by  simple  fission;  sporu- 
lation  has  not  been  shewn  in  this  group.  They 
are  roughly  classified  according  to  their  mode  of 
division :  — 

(a)  Those  which  divide  in  one  axis  only,  forming  a 
chain  of  cocci,  like  a  series  of  golf-balls  in  a  row, 
are  called  Streptococci. 

(b)  Some  arrange  themselves  in  pairs,  these  are 
called  Diplococci.  The  pneumococcus,  which  is  a 
frequent  cause  of  pneumonia,  belongs  to  this  group. 
Diplococci  are  often  also  arranged  in  chains. 

(c)  Those  which  divide  in  two  axes  at  right-angles 


BACTERIOLOGY  3 

to  one  another,  formini;-  sets  of  four  cocci,  like  four 
golf-balls  all  touching,  are  called  Tetracocci  or 
Tetrads.     In  rare  cases  sets  of  sixteen  are  formed. 

(d)  Those  which  divide  in  three  axes  at  rig'ht-angles 
to  one  another,  form  sets  of  eight  cocci  arranged  in  a 
cube;  these  are  called  Sarcince.  The  cocci  are  often 
not  completely  divided  from  one  another,  so  that  the 
masses  of  eight  look  like  bales  of  wool  tied  in  three 
directions. 

(e)  Those  which  divide  irregularly  in  various   axes 


Fig. 


-Tetracocci. 


Fig.  4. — Sarcinae. 


Fig.  5. — Staphylococci. 


Fig.  6.— Bacilli. 


result  in  irregular  masses,  like  bunches  of  grapes,  and 
are  called  Staphylococci. 

(2)  Bacilli,  or  rod-shaped  organisms,  vary  greatly 
in  length.  Their  extremities  may  be  sharp  or  rounded. 
Some  possess  fiagella,  in  varying  numbers,  in  which 
case  they  are  motile.  Reproduction  is  by  simple 
fission,  and  also  in  certain  members  of  the  group  by 
sporulation. 

(3)  Spirilla,  or  curved   organisms,  vary  very  much, 


4  SURGERY    FOR    DENTAL    STUDENTS 

some  being  quite  short  with  only  one  curve,  often 
described  as  comma-shaped,  e.g.,  cholera  organism. 
Others  are  much  longer  and  more  slender,  with  several 
curves.  These  latter  may  be  motile  without  the  aid  of 
flagella,  moving  by  a  waving  motion  of  their  bodies, 
but  many  of  the  group  also  possess  flagella.  Repro- 
duction is  mainly  by  simple  fission;  sporulation  has 
been  described  in  certain  forms. 

The  names  Spirochcute  and  Vibrio  have  been  used, 
as  well  as  Spirillum,  in  describing  members  of  this 
group;  but  as  various  authorities  use  these  terms  with 
varying  significance,  it  has  seemed  wiser  for  our  pur- 
pose to  include  the  whole  group  under  the  name 
Spirilla. 

Of  these  three  classes,  the  first  two  are  of  far 
the   greater   importance   to    surgeons,    and   it   will   be 


Fig.  7.— Spirilla. 

necessary  to  discuss  them  rather  more  in  detail  when 

we   come   to    study   the    diseases   for   which    they    are 

responsible. 

Bacteria   may   also  be   classified  according*   to   their 

method  of  obtaining  nitrogenous  food;  into  {a) 
y  Parasites,  organisms  which  can  only  feed  on  living 
^  animal    or    vegetable    matter,    and    {b)    Saprophytes, 

organisms  which  obtain  their  pabulum  from  dead  or 
//decaying  animal  or  vegetable  matter.   In  between  these 

classes   are   forms   which  prefer   living   food   but   can 

manage  to  exist  on  dead,  and  vice  versa. 

Another  important   feature   in  which   bacteria   differ 

from  one  another  is  their  behaviour  towards  oxygen. 
I     Certain  forms,  classed  together  as  anaerobes,  are  unable 

to  live  in  the  presence  of  oxygen,  while  others,  aerobes. 


BACTERIOLOGY  0 

cannot  exist  without  it.  Again,  there  are  torms  which 
take  up  an  intermediate  position,  favouring  one  or 
other  condition  but  able  to  get  along  under  either. 
These  are  termed  facultative  aerobes,  or  anaerobes,  as 
the  case  may  be. 

Bacteria  are  almost  unanimous  in  their  dislike  to  sun- 
shine, though  the  dislike  is  of  varying  intensity.  For 
instance,  the  bacillus  of  tuberculosis  is  killed  in  a  very 
short  time  if  exposed  to  direct  sunlight,  while  even 
ordinary  London  daylight  is  fatal,  though  in  rather 
longer  time. 

Temperature  also  has  important  bearing  on  their 
activity,  again  in  varying  degree.  The  temperature 
most  favourable  to  their  growth  is  known  as  the 
optimitm  temperature',  it  varies  slightly  with  different 
forms,  but  is  usually  about  37°  C,  that  is,  about  the 
normal  temperature  of  the  human  body.  Though  most 
bacterial  growth  is  inhibited  at  or  below  10°  C,  the 
organisms  are  not  destroyed  by  extreme  cold.  Some 
have  been  found  to  be  alive  and  apparently  happy 
when,  after  an  exposure  for  ten  hours  to  a  temperature 
of  — 250°  C,  they  have  been  again  placed  at  their 
optimum  temperature. 

A  much  greater  effect  is  brought  about  by  the  appli- 
cation of  heat.  Bacterial  growth  usually  ceases  at 
about  40°  C,  and  most  non-sporing  forms  are  destroyed 
at  65°  C.  Some  spores  may  survive  if  boiled  for  a 
short  time,  but  prolonged  boiling-  will  destroy  them. 

This  action  of  heat  upon  bacteria  and  their  spores  is 
of  very  great  practical  importance  to  the  surgeon, 
whatever  his  speciality,  and  we  shall  speak  of  it  again 
when  we  discuss  the  principles  of  asepsis. 

Certain  chemical  substances  also  affect  these 
organisms,  either  inhibiting  their  growth  or  killing 
them  outright.  These  substances  assume  great  im- 
portance in  surgery  under  the  title  of  Antiseptics,  or 
Germicides,  among  which  may  be  mentioned  phenol 
(carbolic  acid),  mercuric  chloride,  iodine,  alcohol,  &c. 

There  are  a  few  micro-organisms,  pathogenic  in 
man,  which  do  not  belong  to  the  class  of  bacteria :  — 

(i)  The  Yeasts  or  Blastomycetes,  which  again  are 
unicellular  fungi,  so  rarely  cause  disease  in  man  that 
we  need  not  consider  them  further. 

(2)  The  Hyphomycetes    compose   another  group   of 


\ 


6  SURGERY    FOR    DENTAL    STUDENTS 

fungi.  They  are  multi-cellular,  and  form  filamentous 
networks,  often  very  complicated.  A  few  of  these  re- 
quire notice,  vis.  :  O'idiuni  albicans,  the  cause  of 
thrush;  Microsporon  Audoidni  and  Trichophyton,  both 
of  which  are  causes  of  ringworm;  and  a  series  of 
organisms  grouped  under  the  name  Streptothrix,  to 
which  the  disease  known  as  Actinomycosis  is  due. 

(3)  Among  the  Protozoa,  or  unicellular  animals,  are 
the  parasite  to  which  malaria  is  due,  and  Spirochwta 
pallida,  which  is  the  organism  of  syphilis. 

Certain  of  these  micro-organisms,  when  they  gain 
access  to  the  human  body,  produce  a  series  of  pheno- 
mena which  we  call  disease.  These  are  known  as 
pathogenic  organisms,  and  it  is  with  these  that  we  are 
chiefly  concerned;  on  the  other  hand,  there  are  some 
which  appear  to  produce  no  effect,  while  others  are 
actually  beneficial.  Some  may  be  normally  quite  harm- 
less, but  under  certain  circumstances  become  patho- 
genic. 

It  is  necessary  to  inquire  what  are  the  effects  pro- 
duced by  the  invasion  of  the  body  by  pathogenic 
organisms. 

These  effects  are  of  three  kinds.  First,  there  may  be 
a  "local  lesion" — that  is,  a  change  produced  in  the 
tissues  in  the  neighbourhood  of  the  invading  organism, 
which  change  may  be  acute  or  chronic.  Examples  of 
acute  local  lesions  are  the  membrane  formed  in  the 
throat  in  diphtheria,  or  the  ulceration  of  the  intestine 
in  typhoid  fever;  and  of  chronic  local  lesions,  tuber- 
culous or  syphilitic  ulceration. 

Secondly,  tissue  changes  may  occur  in  organs  or 
parts  of  the  body  remote  from  the  neighbourhood  of 
the  bacteria.  These  are  due  to  the  absorption  into  the 
blood  of  certain  substances,  known  as  toxins  (poisons), 
manufactured  by  the  bacteria,  and  carried  to  various 
parts  of  the  body  by  the  blood-stream.  These  toxins 
are  of  two  kinds  :  extra-cellular  and  intra-cellular.  The 
extra- cellular  toxins  are  substances  which  are  found  in 
the  fluid  in  which  the  organisms  which  form  them  are 
grown,  and  by  injecting  this  fluid  into  susceptible 
animals  toxic  effects  can  be  produced.  The  chief 
organisms  which  form  extra-cellular  toxins  are  B. 
diphtheria:  and  B.  tetani. 
s^  Intra-cellular  toxins,  on  the  other  hand,  do  not  occur 


BACTERIOLOGY  / 

in  the  fluid  in  which  the  bacteria  are  grown,  and  cannot 
be  produced  under  experimental  conditions.  That  they 
are  formed  in  the  human  body  to  which  the  bacteria 
have  gained  access  we  have  ample  evidence  in  the 
effects  produced  by  them,  examples  of  which  will  be 
found  in  the  following  paragraph. 

Thirdly,  there  are  general  disturbances  of  meta- 
bolism, such  as  fever,  wasting,  &c.  These  effects  again 
are  the  work  of  the  toxins. 

As  regards  the  chemical  nature  of  toxins,  the  little 
that  is  known  shews  them  to  be  of  such  complexity, 
that  to  discuss  the  question  in  a  handbook  of  this  size 
is  quite  undesirable. 

In  the  foregoing  pages  an  attempt  has  been  made 
very  briefly  to  describe  the  vast  army  to  whose  attacks 
the  great  bulk  of  disease  is  due.  Their  energies  are, 
of  course,  directed  towards  their  own  successful  proli- 
feration and  continued  existence;  and  this  goal  cannot 
be  attained  except  at  the  price  of  the  injury  or  death, 
piecemeal  or  entire,  of  the  "  host." 

We  must  now  try  and  see  what  measures  the  human 
organism  employs  to  defend  itself  against  this  invasion. 
Before  doing  this,  there  are  a  few  terms  in  constant  use 
that  need  some  explanation. 

Infection  has  been  defined  as  "the  access  of  living, 
virulent,  pathogenic  organisms  to  a  region  from  - 
whence  their  toxins  may  act  on  the  tissues  of  the  body." 
All  the  conditions  mentioned  in  this  definition  must  be 
fulfilled  before  infection  may  be  said  to  have  occurred. 
First,  the  organisms  must  be  living.  Dead  bacteria 
can  in  some  cases  produce  deleterious  effects,  but  this 
is  not  *'  infection."  Organisms  of  the  sape  species  vary 
considerably,  from  different  causes,  in  their  power 
of  doing  harm.  Some  may  have  so  little  power  that 
they  produce  no  effect  whatever.  These,  though  patho- 
genic, are  not  virulent,  and  therefore  do  not  cause 
infection.  That  the  organisms  must  be  pathogenic  is 
obvious  from  our  definition  of  the  word  pathogenic. 
Lastly,  they  must  be  in  such  a  position  that  their  toxins 
can  act  on  the  tissues.  It  is  quite  possible,  for  in- 
stance, for  "  living,  virulent  pneumococci  "  to  be 
present  in  the  mouth  of  a  healthy  person  without  pro- 
ducing ill  effects.     This  does  not  constitute  infection. 

Infection  may  be  either  local  or  general.     Local  in- 


8  SURGERY    FOR    DENTAL    STUDENTS 

fection  is  that  which  occurs  at  the  point  where  the 
micro-organisms  gain  access  to  the  body.  The  hard 
chancre  of  syphihs  is  an  example. 

General  infection  occurs  when  the  organisms  gain 
access  to  the  blood-stream,  grow  and  multiply  there, 
and  so  produce  general  symptoms.  An  organism, 
once  in  the  blood-stream,  is  liable  to  be  carried  to  any 
part  of  the  body.  The  secondary  stage  of  syphilis  is 
an  example. 

In  most  local  infections  there  is  also  general  in- 
fection to  a  greater  or  less  extent,  while  it  is  rare  for 
a  general  infection  to  be  present  without  some  local 
manifestation.  As  an  example  of  this,  we  may  again 
quote  diphtheria,  in  which  the  local  lesion  in  the  throat 
is  almost  invariably  accompanied  by  general  symptoms, 
usually  very  marked. 

"  Living,  virulent,  pathogenic  bacteria  "  are  present 
in  myriads  all  around  us.  Our  chance  of  escaping  the 
attentions  of  some  at  least  of  these  enemies  would  be 
slender,  indeed,  were  we  not  provided  with  a  natural 
means  of  defence  against  them.  This  natural  means  of 
defence  is  known  as  Immunity.  The  subject  of  im- 
munity is  very  complicated  and  by  no  means  fully 
understood  at  the  present  time,  so  that  it  is  impossible 
in  the  space  at  our  command  to  say  more  than  a  few 
words  upon  it. 

Immunity  may  be  natural  or  acquired.  Natural  im- 
munity is  the  power  of  resisting  disease  inherent  in  the 
animal  at  birth.  It  varies  within  very  wide  limits  in 
different  classes  of  animals,  in  different  races  of  human 
beings,  in  different  individuals  of  the  same  race,  and 
even  in  the  saijie  individual  when  exposed  to  varying 
environment. 

This  latter  point  may  be  better  understood  by 
means  of  an  example.  If  we  sit  in  a  draught  we  are 
liable  to  "  catch  a  cold."  This  so-called  "  cold  "  is 
due  to  the  direct  influence  of  certain  bacteria.  These 
bacteria  are  frequently  present  in  our  mouths  and 
respiratory  tracts  even  when  we  are  perfectly  well; 
but  our  natural  immunity  is  more  than  sufficient  to 
prevent  any  unpleasant  manifestation  of  their  presence. 
Then  we  sit  in  the  draught.  This  in  some  way  lowers 
the  natural  resistance  of  the  body,  and  so  the  micro- 
organisms, powerless  before  to  cause  any  harm,  when 


I 


BACTERIOLOGY 

the  defensive  army  was  strong  and  healthy,  are  able, 
against  the  weakened  opposition,  to  bring  about  those 
changes  in  the  body  that  we  call  a  "  cold." 

Many  other  factors  may  tend  to  lower  the  natural 
resisting  power,  such  as  starvation,  overcrowding, 
wasting  disease  (e.g.,  Diabetes  mellitus),  or  the  action 
of  poisons  (e.g.,  alcohol,  &c.). 

Acquired  immunity  may  be  of  two  kinds  :  active  and 
passive.  Active  immunity  to  a  disease  is  the  increased 
resistance  produced  by  a  previous  attack  of  that 
disease.  Passive  immunity  is  produced  by  the  injec- 
tion into  the  animal  of  some  artificially  prepared  sub- 
stance by  which  immunity  is  conferred. 

Natural  immunity  is  chiefly  due  to  the  activity  of  the 
white  blood  corpuscles.  These  act  mainly  in  two  ways. 
First,  they  actually  ingest  and  destroy  foreign  bodies 
present  in  the  blood-stream.  Secondly,  some  bacteri- 
cidal substances  are  formed  by  the  leucocytes  in  the 
tissues,  and  by  these  bacteria  are  destroyed."  When  any 
injury  to  the  tissues  takes  place,  rendering  the  possi- 
bility of  an  attack  from  outside  easier,  there  is  at  once 
a  great  concentration  of  leucocytes  towards  the  spot  to 
repel  the  invasion.    . 

Various  names  have  been  given  to  these  bactericidal 
substances,  and  many  theories  as  to  their  exact  origin 
have  been  promulgated.  It  will  be  sufficient  for  our 
purpose  if  we  remember  that  we  possess  an  army  of 
leucocytes,  whose  function  it  is  to  wage  war  with  our 
bacterial  enemies;  and  that,  whether  a  disease  ends  in 
recovery  or  no,  depends  upon  the  relative  strengths  of 
invader  and  invaded. 

Acquired  immunity  needs  a  little  further  explanation. 
After  an  invasion  of  bacteria  has  been  successfully 
repelled,  the  patient  will  be  found  to  have  developed 
a  greater  resistance  towards  the  particular  disease,  i.e., 
to  the  activity  of  the  particular  organism,  than  he  pos- 
sessed before  the  attack.  This  is  due  to  the  fact  that 
substances,  known  as  antibodies,  have  been  formed  in 
the  patient's  blood,  which  are  capable  of  rendering 
harmless  the  various  toxic  substances  by  means  of 
which  bacteria  produce  their  deleterious  effect.  This 
is  active  acquired  immunity.  If  the  serum  of  such  a 
patient  containing  these  antibodies  be  injected  into 
the  blood  of  another  animal,  a  certain  amount  of  im- 


10  SURGERY    FOR    DENTAL    STUDENTS 

munity  will  be  conferred  upon  this  second  animal  by 
virtue  of  the  antibodies  injected.  This  is  passive 
acquired  iniviunity . 

Working-  on  this  principle,  a  serum  can  be  artificially 
prepared  in  the  case  of  certain  diseases,  which  serum, 
when  injected  in  proper  dose  and  at  the  proper  time 
into  a  patient  suffering  from  the  particular  disease,  may 
so  increase  his  power  of  resistance  to  that  disease,  that 
he  will  be  enabled  to  recover  from  an  attack  from  which 
his  own  natural  immunity  would  have  been  powerless 
to  preserve  him. 

Notably  is  this  the  case  in  diphtheria,  and  in 
tetanus ;  and  a  glance  at  the  figures  showing  the  death- 
rate  from  diphtheria  before  and  after  the  introduction 
of  the  "  Diphtheria  antitoxin  "  will  amply  suffice  to 
show  the  immense  value  of  this  treatment. 

There  is  another  method  by  which  immunity  may  be 
conferred — viz.,  Yaccination,  to  which  brief  allusion 
must  be  made. 

Vaccination  consists  in  the  injection  into  the  patient 
of  a  ''  vaccine  "  containing  the  living  organisms  of  the 
particular  disease  involved,  the  organisms  being  in  a 
state  of  diminished  virulence.  Dead  cultures  of  the 
organisms  are  also  used  in  certain  cases.  If  the  par- 
ticular organism  by  which  the  patient  is  attacked  can 
be  isolated,  the  vaccine  can  be  prepared  from  this 
org^anism.  The  methods  of  preparation  of  vaccines  are 
too  complicated  to  find  a  place  in  a  manual  of  this  size. 

The  immunity  conferred  by  this  method  is  com- 
parable to  that  which  follows  a  previous  attack  of  the 
disease,  and  is  therefore  classed  as  active  acquired 
iiumunity. 

It  is  a  fascinating  subject,  but  space  has  forbidden 
us  to  do  more  than  dip  into  it.  But  our  readers  may 
be  sure  that  a  more  extensive  study  in  the  many  text- 
books which  deal  fully  with  the  subject  will  more  than 
repay  them,  both  in  interest  and  practical  value. 


CHAPTER  II. 
ASEPSIS   AND    ANTISEPSIS. 

From  the  study  of  Bacteria  and  their  action  upon  the 
human  body,  we  proceed  naturally  to  the  consideration 
of  the  principles  of  asepsis  and  antisepsis,  by  which 
the  whole  system  of  modern  surgical  technique  is 
governed.  First,  to  define  the  meaning'  of  the  words, 
which  will  perhaps  best  be  done  by  means  of  an 
example.  Suppose  we  have  a  pair  of  dressing  forceps. 
We  boil  them  in  water  for  fifteen  minutes.  All  patho- 
genic micro-organic  life  which  might  have  been  present 
on  these  forceps  before  we  began  is  now,  as  far  as 
we  can  tell,  effectually  destroyed.  The  forceps  are 
now  said  to  be  aseptic,  that  is,  free  from  micro- 
organisms. But  again,  suppose  we  lay  them  down  on 
a  table,  exposed  to  the  air  and  dust,  there  is  nothing 
to  'prevent  other  bacteria  finding  their  way  on  to  the 
forceps  again.  In  order  to  meet  this  difficulty,  we  lay 
them  down,  not  on  a  table  but  in  a  dish  containing  a  i  in 
20  solution  of  carbolic  acid,  in  which  solution  bacteria 
cannot  live.  The  forceps  are  now  both  aseptic  and 
antiseptic,  that  is,  free  from  bacteria,  and  in  such  a 
position  that  no  other  bacteria  can  reach  them  alive. 

When  a  wound  has  been  made  in  the  skin  or  mucous 
membrane,  either  by  accidental  injury  or  by  the 
surgeon's  knife,  the  main  factor  in  delaying  or  pre- 
venting healing  is  infection  by  micro-organisms,  chiefly 
those  known  as  pyogenic  organisms  {e.g.,  Strepto- 
coccus and  Staphylococcus  pyogenes).  The  object  of  )/ 
the  surgeon  is,  if  possible,  to  prcA'ent  altogether  the 
entrance  of  micro-organisms  into  the  wound,  or  at 
least  to  limit  the  number  to  such  an  extent  that  the 
patient's  natural  defences  are  sufficient  to  cope  with 
them.  In  the  case  of  an  operation  wound,  or  a  wound 
made  with  a  sharp,  clean  instrument  such  as  a  razor, 
this  task  may  be  comparatively  simple.  In  the  case 
of  an  injury  caused  by  a  blunt,  dirty  instrument  {e.g., 
a  kick  from  a  boot)  it  is  of  course  impossible.   Infection 


12  SURGERY    FOR     DENTAL     STUDENTS 

having  once  occurred,  the  surgeon's  energies  are 
directed  towards  removing  or  destroying  as  far  as 
possible  the  micro-organisms  that  have  gained 
entrance,  preventing  any  further  reinforcement  of  the 
invaders,  and  keeping  up  the  patient's  general  strength 
so  that  his  army  of  leucocytes  may  be  in  best  possible 
fig-hting  trim  to  deal  with  the  invasion  that  has  already 
occurred. 

Neither  asepsis  nor  antisepsis  is  sufficient  by  itself. 
In  order  that  the  best  possible  results  may  be  obtained, 
a  combination  of  the  two  is  required. 

Perhaps  the  best  way  of  shewing  the  various  sources 
of  infection  to  which  an  operation  wound  is  liable,  and 
the  methods  used  to  prevent  it,  will  be  to  describe  in 
a  little  detail  the  performance  of  an  operation. 

Suppose  we  have  to  deal  with  a  patient  who  six 
months  ago  had  an  acute  attack  of  appendicitis,  from 
which  he  recovered  without  operation.  He  is  now 
apparently  perfectly  well;  but,  for  fear  of  a  second 
attack,  is  advised  to  have  his  appendix  removed.  A 
case  like  this  has  been  selected  because  it  is  one  in 
which  there  is  little  or  no  chance  of  infection,  if  aseptic 
principles  are  strictly  obeyed.  There  is  no  acute 
disease  going  on,  there  has  been  no  external  wound 
through  which  infection  might  have  entered,  and  the 
patient's  general  health  is  at  its  best. 

The  chief  points  of  danger  from  the  point  of  view  of 
infection  are  the  hands,  arms,  and  breath  of  the 
operator  and  assistants,  the  instruments  used  in  the 
operation,  and  the  skin  of  the  patient. 

Scrupulous  cleanliness  must  be  observed  in  the 
preparation  of  the  room  in  which  the  operation  is  to 
take  place.  In  a  hospital  this  is  of  course  easy;  in  a 
private  house  it  may  be  extremely  difficult.  In  the 
latter  case,  all  carpets  and  unnecessary  furniture 
should  be  removed,  and  the  walls,  &c.,  well  scrubbed, 
preferably  with  an  antiseptic  lotion,  such  as  per- 
chloride  of  mercury  i   in  i,ooo. 

The  preparation  of  the  patient's  skin  should  be  com- 
menced at  least  the  day  before  operation,  while  some 
surgeons  begin  two  days  before.  The  person  who  is 
to  perform  this  preparation,  usually  a  dresser,  begins 
by  thoroughly  cleaning  his  own  hands.  He  then 
proceeds  to   shave  with  a  razor  the  whole  ''area   of 


ASEPSIS     AND     ANTISEPSIS  I3 

operation."  In  the  case  we  are  describing,  this  would 
include  the  whole  of  the  front  of  the  abdomen,  the 
pubes  and  scrotum,  and  the  upper  part  of  the  front  of 
the  thighs.  The  whole  area  is  then  scrubbed  with  soap 
and  water  and  a  nail-brush  (the  latter  having  been  pre- 
viously boiledj.  The  scrubbing  should  occupy  at  least 
ten  minutes  to  a  quarter  of  an  hour.  Particular  care  is 
necessary  in  dealing  with  the  umbilicus.  The  soap  is 
washed  off  with  some  antiseptic  lotion,  carbolic  i  in 
40  or  perchloride  i  in  i,ooo,  according  to  the  fancy  of 
the  surgeon.  The  skin  is  now  well  rubbed  with  ether 
to  remove  all  greasy  material. 

Up  to  this  point,  the  hands  of  the  dresser  have  only 
been  clean  in  the  ordinary  society  sense  of  the  word.  . 
He  must  now  render  his  hands  surgically  clean,  a  very  v' 
different  condition  indeed.  This  process  of  "  cleaning 
up  "  is  described  later  on,  when  the  surgeon  prepares 
his  hands  before  operating  (p.  i6),  so  we  need  not 
mention  it  here  except  to  say  that  the  process  should 
be  gone  through  every  bit  as  thoroughly  and  con- 
scientiously in  the  preparation  of  the  patient  as  in  the 
actual  operation  (except  that  rubber  gloves,  overalls, 
&c.,  are  not  usually  worn  in  the  former  case). 

The  dresser  now  being  surgically  clean  must  not 
touch  anything  which  is  not  in  a  like  condition,  so 
will  need  an  assistant  to  hand  him  any  bowls,  &c., 
which  he  may  require.  He  first  rubs  the  part  well  with 
methylated  spirit,  followed  by  swabbing  with  carbolic 
lotion  I  in  40.  The  prepared  part  is  now  surgically 
clean;  but  it  has  to  be  kept  so  until  the  next  day.  To 
effect  this,  a  large  piece  of  sterilized  lint  is  wrung-  out 
in  I  in  40  carbolic  lotion,  and  placed  over  the  part. 
It  must  completely  cover  the  area  prepared.  This  in 
its  turn  is  covered  with  some  protective  glazed  paper, 
and  the  whole  firmly  bandaged.  The  process  is  re- 
peated in  its  entirety  on  the  morning  of  the  operation. 
The  success  of  the  surgeon's  endeavour  to  maintain 
asepsis  depends  very  largely  upon  the  care  with  which 
the  preparation  is  carried  out  by  his  subordinates,  and 
the  slightest  carelessness  may  be  followed  by  very 
g'rave  results. 

Another  process  by  which  the  field  of  operation  may 
be  rendered  surgically  clean  has  become  very  popular 
during  the  last  two  or  three  years,  under  the  name  of 


14  SURGERY     FOR     DENTAL     STUDENTS 

the  Iodine  Method.  When  first  introduced  it  was  cus- 
tomary to  shave  and  scrub  the  patient  just  as  ah'eady 
described,  only  using  the  iodine  as  an  additional  pre- 
caution. It  was  found,  however,  that  if  this  were 
done,  the  iodine  did  not  penetrate  the  skin  to  any 
y^tent,  and  the  results  obtained  were  consequently  un- 
^  favourable.  Practice  has  shown  that  in  order  to  obtain 
the  best  results  the  iodine  solution  must  be  painted  on 
without  any  previous  treatment  of  the  part  with  soap 
or  razor.  (Some  surgeons  prefer  the  part  to  be 
shaved,  but  if  so  a  dry  razor  is  used.) 

Originally,  solutions  containing  6  per  cent,  or  even 
8  per  cent,  of  iodine  were  used,  but  it  was  soon  found 
that  this  strength  was  too  irritating  to  the  skin.  Solu- 
tions of  2  per  cent,  to  2j  per  cent,  were  substituted: 
\  and  these  are  found  just  as  efficacious  in  maintaining 
asepsis,  while  irritation  is  reduced  to  a  minimum. 

Various  solvents  have  been  tried.  Methylated  spirit 
causes  more  irritation  than  rectified  spirit.  Iodine  dis- 
solved in  acetone  is  said  to  be  more  bactericidal  than 
either,  but  is  far  more  irritant.  With  all  these  solu- 
tions pungent  odours  are  evolved,  causing  great 
lachrymation  to  the  nurse  or  dresser  whose  duty  it  is 
to  apply  them. 

The   application   in   most   common    use    now    is    a 

saturated    solution    of    iodine    in    ethylene    dichloride 

\         (C2H2CI2).      This  contains    2.48   per   cent,    of   iodine. 

\       Slight  tingling  of  the  skin  is  caused  on  application,  but 

there  is   practically  no   subsequent  irritation,   and   no 

pung'ent  odours  are  evolved. 

The  methods  employed  by  different  surgeons  vary 
slightly  in  detail,  but  the  following  will  be  found  to 
fulfil  all  requirements. 

About  two  hours  previously  (or  less,  in  cases  of 
emergency)  the  field  of  operation  is  painted  with  a 
solution  of  equal  parts  of  ethylene  dichloride  and 
methylated  spirit,  by  means  of  sterile  swabs.  This  is 
followed  by  swabbing  with  pure  ethylene  dichloride. 
The  saturated  iodine  solution  is  then  painted  on,  and 
the  whole  area  covered  with  sterile  lint,  and  bandaged. 
When  the  patient  is  under  the  anaesthetic,  and  on  the 
operating  table,  the  iodine  solution  is  painted  on  once 
more. 

There  are  some  slight  disadvantages  connected  with 


ASEPSIS     AND     ANTISEPSIS  1 5 

the  iodine  method.  First,  the  vascularity  of  the  tissues 
is  increased,  and  the  superficial  haemorrhage  conse- 
quently greater.  Secondly,  the  skin  is  hardened,  and 
the  edges  of  knives,  &c.,  are  dulled  sooner  than  with 
the  other  process. 

The  advantages  of  the  method,  on  the  other  hand, 
are  of  extreme  importance.  As  far  as  is  shewn  by 
the  figures  at  present  available,  the  results  obtained 
are  every  bit  as  satisfactory  as  with  the  older  and 
lengthier  process.  There  is  obviously  great  saving  of 
time :  in  cases  requiring  immediate  operative  inter- 
ference, this  is  of  immense  value.  The  shaving  and 
scrubbing,  which  the  older  method  entails,  are  a  source 
of  great  annoyance  to  the  patient.  They  are  lengthy 
and  disagreeable  at  the  time;  they  frequently  cause 
considerable  mental  distress,  leading  to  a  disturbed 
night's  rest,  a  very  bad  preparation  for  the  shock  of 
an  operation  on  the  morrow.  Furthermore,  the  irri- 
tation caused  by  the  growing  of  hair  on  the  shaven 
parts  is  very  tiresome  during  convalescence.  All  these 
troubles  are  avoided  by  the  use  of  the  method  just 
described,  and  it  appears  likely  that  it  will  become 
more  and  more  popular  as  its  advantages  are  more 
widely  recognized. 

All  instruments  to  be  used  during  the  performance 
of  the  operation  must  be  boiled  for  fifteen  minutes, 
and  then  placed  in  sterilized  water,  or  some  antiseptic 
fluid  (e.g.,  carbolic)  until  required  by  the  surgeon. 
(N.B. — Perchloride  of  mercury  should  not  be  used,  as 
metallic  instruments  are  injured  by  it.) 

There  are  two  classes  of  persons  required  at  the 
operation  itself,  clean  and  unclean  (in  a  surgical  sense). 
Both  classes  are  essential,  and  their  duties  quite  dis- 
tinct. All  that  involves  the  touching  of  the  area  of 
operation,  or  of  anything  which  is  to  come  near  this 
area,  such  as  an  instrument,  or  a  sterilized  towel,  must 
be  done  by  a  clean  person.  Everything"  in  which  sur- 
gically dirty  things  are  involved,  such  as  lifting  the 
patient  on  to  the  operating  table,  or  holding  a  bowl 
of  antiseptic,  falls  to  the  lot  of  the  unclean. 

It  is  obviously  necessary  to  arrange  for  some  con- 
necting link  between  the  clean  and  the  unclean.  For 
this  purpose,  a  pair  of  forceps  at  least  a  foot  long  is 
used.     The  forceps  are  sterilized  by  boiling,  and  then 


l6  SURGERY    FOR     DENTAL     STUDENTS 

placed  in  a  tall  jar  containing  sufficient  antiseptic 
(usually  methylated  spirit)  to  cover  the  beaks  of  the 
instrument,  the  beaks  thus  being  kept  sterile.  An 
unclean  person  may  hold  this  instrument  by  the  handle, 
and  with  it  pick  up,  say,  an  instrument  from  a  dish  of 
antiseptic,  and  place  it  upon  the  sterile  towel  with 
which  the  area  of  operation  is  surrounded  (vide  infra), 
without  any  contamination  occurring.  The  forceps 
must  then  be  returned  to  their  tall  jar  until  again 
required,  care  being  taken  that  the  beaks  touch  nothing 
dirty  in  transit. 

If  these  principles  are  strictly  adhered  to,   nothing 
comes    near    the    field    of    operation,    which    has    not 
been  previously  sterilized.     We  must  now  describe  the 
methods  by  which  a  person  taking  part  in  the  operation 
must  render  himself  surgically  clean.     First  he  scrubs 
his  hands  and  forearms  for  ten  minutes  with  soap  and 
water  and  a  boiled  nail  brush.     He  then  washes   of¥ 
the  soap  with  sterilized  water.     Next  he  rubs  his  hands 
and   forearms   again   for   several   minutes   with   gauze 
soaked  in  methylated  spirit,  and  then  rinses,  in  either 
I  in  40  carbolic  or  i  in  1,000  perchloride  lotion.       He 
then    puts    on    a    linen    overall,    previously    sterilized. 
These  overalls  are  made  to   fasten  w^ith  tapes  at  the 
back,  so  that  the  fastening  can  be  done  by  an  unclean 
assistant.     A  sterilized  linen  cap  is  put  on  his  head,  so 
as  to  cover  all  the  hair.     A  piece  of  gauze  folded  in 
four  layers  is  passed   over  his  mouth  and  nose,   and 
either  pinned  or  clipped  at  the  back.     He  then  puts  on 
boiled  rubber  gloves,  into  the  wrist  portion  of  which 
the  end  of  the  sleeves  of  his  overall  are  slipped.     If 
the    hand    be    previously    moistened    with    methylated 
spirit,  the  gloves  will  be  found  to  slip  on  quite  easily. 
The  patient,  having  been  anaesthetized,  is  lifted  on 
to    the   table.       The    anaesthetist    sometimes    wears    a 
gauze  mask,   but  this    precaution    is    not    universally 
adopted.       The  bandages  are  removed  by  an  unclean 
assistant,  who  next  takes  hold  of  the  protective  paper 
and  the  lint,   his   hand  being   outside  the  paper,    and 
removes  the  two  together,  avoiding  touching  the  pre- 
pared   area.        Sterile    towels    are    now    arranged    all 
around   the   area   of   operation,    only  leaving   exposed 
just    sufficient    surface    for    the    surgeon's    purpose. 
During  the  performance  of  the  operation,  these  aseptic 


ASEPSIS     AND     ANTISEPSIS  1/ 

principles  are  strictly  followed.  A  basin  is  close  at 
hand,  in  which  the  surgeon  may  rinse  his  hands.  It 
may  contain  sterilized  water  or  some  antiseptic  accord- 
ing to  the  taste  of  the  operator.  In  either  case,  the 
fluid  must  be  constantly  changed. 

These  arrangements  may  appear  at  first  rather 
fantastic  and  overdone,  more  so  in  print  than  in  actual 
practice.  But  if  normal  healing  of  the  wound  is  to 
be  secured,  it  is  essential  that  no  precaution  be 
neglected  by  which  the  entrance  of  bacteria  can  be 
prevented  or  even  hindered.  And  practice  has  shewn 
that  the  only  method  of  attaining  this  end  is  to  be 
scrupulously,  one  might  almost  say  absurdly,  careful 
over  every  little  point  in  the  complicated  ritual  of 
asepsis;  and  to  remember  that  the  slightest  careless- 
ness in  even  the  most  insignificant  detail  may  cause 
infection  of  the  wound,  and  so  at  least  delay  healings 
or  even  endanger  the  patient's  life. 


CHAPTER  III. 
INFLAMMATION. 

Inflammation  has  been  defined  in  various  ways. 
Perhaps  the  simplest  and  best  definition  is  that  of 
Sidney  Martin:  "Inflammation  may  be  considered 
as  the  reaction  of  the  tissues  to  the  irritant  effect  of 
an  injury  .  .  .  ."  Dr.  Martin  further  divides  injuries 
into  four  classes,  mechanical,  chemical,  thermal,  and 
bacterial. 

There  are  five  cardinal  signs  of  inflammation  in  a 
part,  vi^.,  redness,  swelling",  heat,  pain,  and  impair- 
ment of  function.  None  of  the  five  are  invariably 
present,  and  they  vary  according  to  the  situation  of 
the  injury. 

The  phenomena  which  occur  in  inflammation  can  be 
studied  microscopically  in  the  web  of  a  frog's  foot, 
to  which  an  irritant  has  been  applied.  Although,  for 
the  sake  of  clearness,  the  process  is  described  as  con- 
sisting of  a  series  of  distinct  stages,  it  must  be  clearly 
understood  that  it  is  really  continuous,  all  the  stages 
running  into  one  another. 

The  earliest  changes  are  in  the  vessels.  First,  a 
dilatation  of  the  vessels  occurs,  affecting  the  arterioles 
most,  to  a  less  extent  the  venules,  and  the  capillaries 
least  of  all.  This  dilatation  is  the  result  of  injury  to 
the  vessel  itself :  it  is  not  carried  By  the  nervous 
system,  as  is  shewn  by  the  fact  that  it  occurs  eA^en  if 
the  nerves  to  the  part  have  been  cut. 

At  first,  the  Avascular  dilatation  is  accompanied  by 
an  acceleration  of  the  rate  of  flow  of  the  blood;  but 
after  a  while  this  is  replaced  by  a  gradually  increasing 
retardation,  due  to  alteration  in  the  A^essel  walls,  and 
also   in  the  capillary  pressure. 

The  movements  of  the  corpuscles  in  this  stage  may 
be  compared  to  a  crowd  of  people  rushing  along  a 
street.  At  the  end  of  the  street  we  must  imagine  some 
obstruction  to  their  progress,  so  that  as  they  pass  us 


INFLAMMATION  I9 

they  are  seen  to  go  gradually  slower;  later  on,  when 
the  obstruction  in  front  does  not  break  down,  and  the 
pressure  from  behind  continues,  they  begin  to  oscillate 
backwards  and  forwards  (period  of  oscillation)  till  at 
last  they  come  to  a  standstill  (period  of  stasis). 

From  the  commencement  of  the  process,  the  white 
corpuscles  will  have  been  seen  to  collect  along  the  / 
walls  of  the  vessels;  and  the  red  corpuscles  also  tend 
to  stick  together,  and  to  the  vessel  walls,  forming- 
rouleaux.  This  accumulation  of  leucocytes  along  the 
walls  tends  to  increase  the  narrowing  of  the  lumen  of 
the  vessels,  while  the  adhering  together  of  the 
corpuscles  makes  it  increasingly  difficult  for  them  to 
pass  along  their  normal  course.  Thus  both  these 
factors  favour  a  condition  of  stasis.  The  process  up 
to  this -point  is  known  as  the  stage  of  hyperemia. 

The  next  stage  is  that  of  exudation.  The  fluid 
exuded  may  be  of  two  kinds,  serous  or  plastic. 

In  slight  inflammations,  and  in  early  stages  of  more 
severe  ones,  there  is  merely  an  increase  in  the  amount 
of  normal  fluid  exuded  into  the  tissues,  and  no  change 
in  the  character  of  the  fluid.  This  is  called  serous  ,. 
exudation,  and  the  fluid  is  composed  chiefly  of  blood 
serum,  and  is  non-coagulable.  In  the  later  stages, 
however,  there  comes  a  change  in  the  character  of 
the  fluid.  Numerous  leucocytes  are  found  in  it,  and 
it  is  readily  coagailable,  owing  to  the  presence  of  the 
flbrin-form.ing  elements  of  the  blood.  This  is  plastic, 
exudation.    The  fluid  is  often  called  "  lymph."  ^ 

Fairly  early  in  the  process  of  inflammation,  the 
leucocytes  begin  to  make  their  w^ay  through  the  vessel 
walls,  and  the  tnore  intense  the  inflammation,  the  ^ 
greater  the  number  of  leucocytes  that  pass  out.  The 
leucocytes  lying  along-  the  vessel  walls  in  the  stage  of 
retardation  of  the  blood  seem  at  first  to  push  out  the 
wall  into  a  sort  of  hump.  This  hump  increases  in 
size  until  it  is  held  just  by  a  stalk.  The  wall  unites 
again  on  the  inner  side  of  the  hump,  and  then  the 
stalk  gives  way,  leaving  the  leucocytes  outside  the 
vessel,  though  no  break  of  continuity  in  the  wall 
remains.     This  phenomenon  is  known  as  diapedesis. 

In  some  cases  of  inflammation  no  diapedesis  occurs. 
In  order  to  explain  this,  it  has  been  suggested  that 
different  irritants  have  different  chemical  effects  upon 


xy 


20  SURGERY    FOR    DENTAL    STUDENTS 

the  leucocytes,  some  attracting  and  some  repelling 
them.  The  name  "  positive  chemiotaxis  "  is  given  to 
the  former  condition,  while  the  latter  is  called 
'^  negative  chemiotaxis." 

The  rapid  exudation  of  a  large  quantity  of  fluid 
naturally  exerts  considerable  pressure  upon  surround- 
ing structures,  especially  in  tissues  which  are  not 
capable  of  stretching  much.  This  may  irritate  the 
nerves  of  the  part,  bringing  about  pain,  one  of  the 
tive  cardinal  signs  mentioned  above.  It  may  also 
interfere  to  a  greater  or  less  extent  with  the  blood 
supply.  In  some  cases  the  vessels  may  be  so  much 
compressed  as  to  stop  the  flow  of  blood  altogether. 
If  this  condition  be  not  relieved  it  results  in  death  of 
the  part  (gangrene,   q.v.). 

The  special  name  of  catarrh  has  been  given  to  a 
form  of  inflammation  which  affects  epithelial  surfaces, 
and  is  accompanied  by  hyperaemia,  and  exudation  of 
fluid,  first  serous,  and  later  plastic.  It  occurs  most 
commonly  in  mucous  surfaces,  such  as  the  nasal 
mucous  membrane.  The  pain  in  these  conditions  is. 
described  as  smarting  in  character  with  ^  feeling  of 
grittiness;  this  is  very  characteristic.  (Eczema  is  a 
catarrhal  inflammation   of  the   skin.) 

Inflammation  may  terminate  in  a  variety  of  ways. 

(i)  When  the  injury  is  so  slight  that  the  vitality  of 
the  tissues  of  the  part  is  not  destroyed,  resolution 
may  occur.  This  consists  of  a  simple  reversal  of  the 
process  described,  the  affected  part  being  restored  to 
its  original  condition.  The  stationary  corpuscles  first 
begin  to  oscillate  backwards  and  forwards;  then  the 
blood-stream  gradually  moves  forwards  once  more, 
gradually  increasing  in  rate  until  the  normal  speed  is 
attained,  just  as  the  queue  waiting  at  the  pit  door  of 
a  theatre  behaves  when  the  doors  are  open.  The 
exuded  fluid  is  removed  by  the  lymphatics.  The 
leucocytes  which  have  escaped  by  diapedesis  return  to 
the  circulation  either  via  the  lymphatics,  or  else  by  a 
similar  method  to  that  by  which  they  left  it.  Some  of 
them  may  be  actually  absorbed  in  the  tissues.  Resolu- 
tion is  very  rarely  seen  in  inflammation  of  bacterial 
origin,  but  more  commonly  when  mechanical  injury  is 
the  exciting  cause. 

(2)  When  the  vitality  of  the  tissues  has  been  to  some 


f 


INFLAMMATION  21 

extent  destroyed,  the  dead  tissue  may  disappear,  and 
fibrous  scar  tissue  take  its  place.  This  is  known  as 
repair.  The  fibrous  tissue  is  formed  by  the  connec- 
tive tissue  cells. 

(3)  If  the  irritant  be  still  more  intense,  suppuration 
may  occur.  The  exudate  and  the  dead  tissues  become 
liquefied,  and  pus  is  formed.  Pus  consists  of  the 
liquefied  tissues  of  the  part,  and  the  fluid  exudate,  in 
which  float  numerous  dead  and  living  leucocytes. 

(4)  In  still  more  intense  inflammations,  the  vitality 
of  large  areas  of  tissue  may  be  destroyed,  and 
gangrene  is  said  to  have  occurred. 

(5)  When  the  suppuration  or  the  gangrene  affects 
an  epithelial  surface,  it  is  known  as  ulceration  (q.v.). 
If  the  irritant  continues  to  act  for  a  prolonged  period, 
the  result  is  a  chronic  inflammation.  Considerable 
fibrous  thickening  of  the  part  usually  occurs;  the 
exudation  of  lymph  may  be  organized  into  fibrous 
bands  (adhesions),  or  the  fluid  exudation  may  persist 
as  a  chronic  effusion. 

The  main  difference  between  an  acute  and  chronic 
inflammation  is  that,  in  the  latter,  the  reaction  of  the 
tissues  is  much  greater,  a  large  amount  of  fibrous 
tissue  being"  formed.  Suppuration  occurs  less  fre- 
quently in  chronic  inflammation. 

The  clinical  signs  of  inflammation  are  local  and 
general.  The  local  signs  have  been  already  mentioned, 
vie. :  Redness,  swelling,  heat,  pain,  and  impairment 
of  function.  The  heat  and  redness  are  due  to  the 
hypersemia;  the  swelling  partly  to  the  hypersemia,  but 
chiefly  to  the  exudation  of  fluid;  while  irritation  of 
the  peripheral  nerves  is  responsible  for  the  pain.  The 
impairment  of  function  may  be  secondary  either  to 
the  swelling  or  pain,  or  both,  or  to  the  effect  of  the 
bacterial  toxins  on  the  cell  protoplasm. 

The  general  signs  vary  according  to  the  part 
involved,  and  the  cause  of  the  inflammation. 

If  an  important  organ  is  involved,  symptoms 
dependent  upon  the  impairment  of  function  of  that 
organ  may  be  present.  Slight  temporary  pyrexia 
(fever)  may  occur  in  simple  non-bacterial  inflamma- 
tions. 

Bacterial  inflammations,  especially  when  suppuration 
has  occurred,  are  almost  always  accompanied  by  fever. 


22  SURGERY     FOR     DENTAL     STUDENTS 

The  temperature  is  elevated,  the  pulse  and  respirations 
rapid  in  proportion.  If  the  condition  goes  on,  the 
tongue  becomes  dry  and  furred,  the  lips  and  teeth  are 
covered  with  collections  of  dried  mucus  (sordes),  the 
skin  is  dry  and  hot,  the  patient  passes  a  small  amount 
of  highly  coloured  urine  which  frequently  contains 
large  deposits  of  urates,  and  often  a  trace  of  albumen; 
constipation  is  the  rule,  but  diarrhoea  may  occur. 

In  the  case  of  specific  infections,  symptoms  depen- 
dent on  the  action  of  the  specific  bacterial  toxin  may 
supervene.  When  suppuration  occurs,  as  has  been 
described,  a  certain  amount  of  normal  tissue  is 
destroyed,  and  the  debris  collects  as  pus.  When  this 
collection  of  pus  is  contained  in  a  definite  walled-in 
cavity,  it  is  known  as  an  abscess.  When  the  signs  of 
inflammation  are  well  marked,  and  the  abscess  forms 
rapidly,  it  is  an  acute  abscess  :  this  is  most  commonly 
due  to  pyogenic  cocci.  A  chronic  abscess  is  one  which 
forms  slowly,  without  signs  of  intense  inflammation. 
Owing  to  the  prolonged  irritation,  there  is  usually 
considerable  fibrous  thickening  of  the  walls  of  the 
abscess  cavity.  It  is  less  commonly  due  to  pyogenic 
cocci  than  the  acute  variety.  Dead  streptococci  or 
staphylococci  may  sometimes  be  responsible  for  a 
chronic  abscess.  The  tubercle  bacillus  is  a  common 
cause.  When  the  pus  is  diffused  throughout  the  tis- 
sues, without  any  definite  abscess  cavity,  the  condition 
is  termed  diffuse  suppuration  or  cellulitis.  In  all 
cases  of  suppuration,  the  tissues  involved  tend  gradu- 
ally to  die,  and  are  cast  off  in  the  pus.  In  the  more 
intense  inflammations,  these  portions  of  necrotic  (dead) 
tissue  may  be  of  sufficient  size  to  be  easily  visible,  and 
to  be  seized  with  forceps;  they  are  then  known  as 
sloughs.  When  a  whole  large  area  of  tissue  dies,  it 
is  said  to  be  gangrenous  (q.v.). 

A  cold  abscess  is  one  in  which  the  formation  of  pus 
is  so  rapid  that  from  this  point  of  view  the  abscess 
wotild  be  called  acute;  on  the  other  hand,  the  signs 
of  acute  inflammation,  vis.,  redness,  heat,  swelling, 
pain  are  little  in  evidence.  There  is  seldom  much 
thickening  of  the  walls,  and  the  pus  is  usually  thin  and 
watery.  These  abscesses  are  mostly  tuberculous  in 
origin. 

When  an  abscess  heals,  it  does  so  by  the  formation 


IXFLAMMATIOX  23 

of  new  tissue  (granulation  tissuej  similarly  to  the 
method  of  healing"  of  an  ulcer  iq.z'.),  the  granulations 
gradually  forming  from  the  bottom. 

It  sometimes  happens  that  something  remains  behind 
in  the  abscess  cavity  after  it  has  been  opened,  such  as 
a  foreign  body,  a  piece  of  dead  bone,  a  little  pus  which 
is  unable  to  escape,  &c.,  which  keeps  up  the  irritation. - 
The  abscess  may  then  not  completely  close;  a  thin 
track  remains  leading  down  to  the  bottom  of  the 
abscess,  its  opening  generally  containing  abundant 
sprouting  granulation  tissue,  and  discharging  pus. 
This  is  called  a  sinus.  On  the  removal  of  the  source 
of  irritation,  healing  usually  occurs  rapidly.  It  is 
important  to  recognize  the  difference  between  a  sinus, 
as  described  above,  and  a  fistula.  A  fistula  is  an 
abnormal  communication  between  two  cavities  nor- 
mally present  in  the  body  (e.g.,  a  recto-vesical  fistula 
between  the  rectum  and  the  urinary  bladder)  or 
between  one  such  cavity  and  the  surface  of  the  body. 
A  sinus  is  an  abnormal  communication  between  the 
surface  of  the  body  and  an  abnormal  cavity  such  as 
an  abscess  cavity. 

It  may  be  useful  at  this  point  to  review  the  subject 
briefly  by  means  of  a  simile.  In  a  bacterial  inflamma- 
tory process,  the  active  elements  concerned  may  be 
very  roughly  divided  into  three  classes :  first,  the 
leucocytes,  whom  we  may  liken  to  policemen;  the 
bacteria,  who  are  foreign  and  undesirable  aliens;  and 
the  red  corpuscles,  the  ordinary  "  men  in  the  street,'^ 
useful  and  desirable  in  their  proper  place,  and  when 
fulfilling  their  proper  function,  but  extremely  tiresome 
when,  for  one  reason  or  another,  they  do  not  do  their 
duty. 

The  whole  trouble  is  begun  by  the  undesirable  alien, 
and  to  effect  a  cure,  this  class  must  be  as  far  as  possible 
annihilated.  By  the  action  of  these  bacteria,  the  red 
corpuscles  are  induced  to  leave  off  work,  and  collect 
in  crowds  aroimd  the  injured  spot,  "  on  strike  "  as  it 
were,  and  hindering  the  police  in  the  execution  of  their 
duty.  It  is  neither  necessary  nor  desirable  to  destroy 
this  class.  If  the  crowd  of  loafers  be  "  moved  on  " 
to  other  healthy  parts  of  the  body,  where  the  local 
police  are  able  to  deal  with  them,  that  is  all  that  is 
needed. 


24  SURGERY     FOR     DENTAL     STUDENTS 

If  in  an  encounter  between  police  and  invaders,  there 
are  many  casualties  on  either  side,  the  dead  bodies 
remain  about  the  battlefield  in  the  shape  of  pus.  This 
naturally  hinders  the  remaining  leucocytes  from  deal- 
ing" effectually  with  the  invading  bacteria,  and  must  be 
got  rid  of  at  once. 

The  treatment  of  inflammation  is  founded  practically 
on  these  principles  :  — 

(ij  If  possible,  remove  the  exciting  cause.  If  it  be 
bacterial,  by  free  incision,  scraping  away  dead  or 
diseased  tissues,  and  the  application  of  antiseptics.  If 
suppuration  has  occurred,  it  is  essential  that  ffee  exit 
should  be  given  to  the  pus.  Any  foreign  body  should 
be  removed. 

(2)  Prevent  any  further  invasion  by  careful  anti- 
septic dressing-. 

(3)  Get  rid  of  the  crowds  of  red  corpuscles  which 
are  in  the  way,  or,  to  put  the  same  idea  in  surgical- 
language,  reduce  the  hyperemia.  This  may  be  done 
in  a  variety  of  ways.  Blood  may  actually  be  removed 
from  the  circulation  by  means  of  leeches,  cupping,  or 
actual  incisions.  Counter-irritation  also  aims  at  the 
same  thing,  by  withdrawing  blood  from  the  diseased 
area  to  the  healthy  parts  around.  If  the  inflammation 
is  in  a  limb,  the  elevation  of  the  part  will  assist  in 
reducing  the  hypersemia,  as  also  will  the  application  of 
cold  by  means  of  an  icebag,  or  iced  water  run  through 
Leiter's  tubes  (coils  of  narrow  metal  tubes  made  to 
encircle  the  part,  through  which  a  stream  of  iced  w^ater 
is  forced).  The  application  of  cold  is  only  advisable 
quite  in  the  early  stages,  as  it  tends  to  depress  the 
general  vitality  of  the  part. 

In  chronic  cases,  Scott's  dressing  (Ung.  Hydrarg. 
Co.)  and  massage  are  used. 

(4)  The  application  of  moist  heat  is  a  very  common 
method  of  treatment.  It  acts  by  causing  dilatation  of 
the  vessels,  and  so  relieving  the  pain  by  lessening  the 
tension.  It  increases  the  general  vitality  of  the  part, 
and  hastens  the  return  of  the  normal  circulation. 

(5)  Rest  is  an  extremely  important  part  of  the 
treatment.  There  is  quite  enough  to  be  done  in  clear- 
ing out  the  invaders,  and  repairing  the  damage  done, 
without  any  additional  work  in  the  way  of  active  move- 
ment of  the  part. 


IXFLAMMATIOX  2^ 

(6)  The  patient's  general  strength  must  be  kept  up 
by  the  administration  of  tonics,  &c. ;  and  the  ehmina- 
tion  of  toxic  substances  from  the  system  induced  by 
purgation  and  diuresis. 

(y)  In  inflammations  due  to  specific  causes,  drugs 
which  have  a  specific  action  in  the  malady  shbuld  be 
administered,   e.g.,   salicylates  in  rheumatism. 

f8)  In  those  bacterial  infections  in  which  an  anti- 
toxin  has  been  prepared,  such  as  tetanus  or  diph- 
theria, a  suitable  dose  should  be  given. 

(9)  A  vaccine  mav  be  prepared,  and  administered 
fp.  10). 


CHAPTER  IV. 
ULCERATION. 

Ulceration,  or  progressive  molecular  death,  as  it 
has  been  termed,  is  the  death  of  small  portions  of 
tissue.  It  is  due  to  irritation  followed  by  inflamma- 
tion and  destruction  of  tissue.  Any  general  condition 
which  tends  to  depress  tissue  vitality  will  act  as  a 
predisposing  cause   of  ulceration. 

Ulcers  may  be  divided  into  two  main  groups :  — 
Simple  and  Malignant.  The  latter  are  dealt  with  in 
Chapter  XIV.  Simple  ulcers  may  be  further  divided 
into  those  due  to  the  action  of  a  specific  micro-organ- 
ism (syp'hilis,  tubercle,  &c.j,  and  those  due  either  to 
the  non-specific  pyogenic  micro-organisms  or  to  injury. 
The  former  are  considered  together  with  the  diseases 
of  which  they  are  a  manifestation.  The  latter  must 
be  dealt  with  in  a  little  detail  here. 

For  the  sake  of  clearness,  three  stages  of  simple 
ulceration  are  described  :  — Extension,  Transition,  and 
Healing.  It  will  be  well  to  reiterate  here  what  was 
pointed  out  when  discussing  the  various  stages  of 
inflammation,  that  all  the  stages  run  imperceptibly  into 
one  another.  It  is  not  possible  to  draw  a  sharp  line 
between  one  stage  and  another:  to  say,  ''  Before  that 
point,  the  ulcer  is  in  the  stage  of  extension,  and  after 
that  point,  in  the  stage  of  transition." 

Stage  1. — Extension. — The  typical  ulcer  in  this  stage 
has  a  dirty  grey  surface  with  thickened  margins;  the 
surrounding  tissues  are  usually  red  and  inflamed.  The 
base  of  the  ulcer  is  thickened  and  hard,  and  often 
fixed  to  the  tissues  beneath  it.  There  is  generally  a 
considerable  quantity  of  thin,  watery  discharge,  often 
containing  escaped  blood,  but  not  much  pus. 

Stage  2. — Transition. — The  surface  gradually  loses 
its  dirty  grey  colour,  and  is  covered  with  a  film  of 
exudation.  This,  later  on,  becomes  dotted  over  with 
little  pink  granulations  which  increase  in  number  until 
they  cover  the  whole  surface.     There  is  less  thickening 


ULCK RATION  2^ 

of  the  margins  and  base;  the  discharge  is  less  in 
amount. 

Stage  3. — Healing. — The  ulcer  now  has  a  smooth  red 
surface,  covered  with  granulations.  There  is  no 
marked  thickening  of  the  margins  or  base;  the  dis- 
charge is  almost  absent,  unless  sepsis  occurs,  when  it 
will   become   purulent. 

The  margin  of  a  healing  ulcer  is  described  as  con- 
sisting of  three  zones  of  colour,  the  colour  being 
modihed  by  the  amount  of  epithelium  present.  The 
outermost  zone  is  composed  of  practically  healed 
tissue,  and  is  whitish  in  colour;  the  innermost  zone 
consists  of  granulation  tissue,  and  is  therefore  red; 
while,  in  between,  the  granulation  tissue  is  covered  by 
more  or  less  epithelium,   forming  a  bluish  zone. 

Many  varieties  of  injury  may  be  responsible  for 
ulceration.  As  examples  we  may  mention  irritation 
from  the  rubbing  of  a  rough  boot,  pressure  and  irrita- 
tion of  badly  padded  splints,  burns,  scalds,  bedsores. 

There  are  certain  special  forms  of  chronic  ulcer  that 
demand  special  mention. 

Varicose  ulcers  occur  on  the  legs  of  patients  suffer- 
ing from  varicose  veins.  They  are  usually  situated  in 
the  lower  and  inner  part  of  the  leg,  on  account  of 
the  venous  distribution. 

The  surface  is  usually  of  a  greyish  colour,  often 
discharging  thin  watery  pus.  The  edges  are  clean 
cut,  but  as  a  rule  irregular;  they  are  often  thick  and 
overhanging.  The  base  is  attached  to  underlying- 
parts,  often  to  the  bone.  Ulcers  of  this  type  are 
described  in  patients  who  do  not  suffer  from  varicose 
veins.  They  are  then  called  callous  ulcers,  but  do  not 
differ  in  any  other  respect  from  the  varicose  varietv. 
Both  these  forms  of  ulcer  may  be  the  seat  of  carcino- 
matous changes  (vide  p.   112). 

In  certain  cases,  peripheral  nerve  filaments  appear 
on  the  surface  of  the  ulcer,  forming  spots  exquisitely 
tender  to  touch.  The  name  irritable  ulcer  is  given  to 
these. 

An  eczematous  condition  of  the  surrounding  skin, 
due  to  the  irritation  caused  by  the  discharge,  is  a 
frequent  complication  of  these  ulcers. 

The  treatment  of  an  acute  ulcer  is  quite  simply 
divisible  into  three  heads  :  — 


28  SURGERY     FOR     DENTAL     STUDENTS 

(i)  Remove  the  cause. 

(2)  Render  the  part  aseptic  and  keep  it  so.  The 
method  most  commonly  adopted  is  to  apply  boracic 
fomentations.  During  the  healing  stage,  greasy 
preparations,  such  as  boracic  acid  ointment,  are  substi- 
tuted for  the  fomentations.  Prominent  granulations 
should  be  checked  by  the  application  of  solid  silver 
nitrate.  Lotio  rubra,  a  solution  of  zinc  sulphate, 
coloured  with  compound  tincture  of  lavender,  is  of 
great  value  in  the  healing  stage. 

(3)  Keep  the  part  at  rest. 

When  the  surface  of  the  ulcer  is  very  large,  skin 
grafting  may  be  required. 

The  treatment  of  chronic  ulcers  is  often  very  tedious 
and  unsatisfactory.  The  chief  reason  for  this  is, 
that  these  ulcers  most  commonly  occur  in  women  of 
the  lower  classes,  who  cannot  rest  and  will  not  keep 
clean.  And  as  rest  and  cleanliness  practically  sums 
up  the  treatment,  failure  is  hardly  a  surprise. 

Where  the  varicose  condition  of  the  veins  is  very 
extreme,  operative  treatment,  which  consists  in 
removal  of  the  dilated  veins  above  the  ulcer,  should 
be  practised.  This  again  is  difficult,  as  the  class  of 
patient  with  whom  one  has  to  deal  can  rarely  spare 
the  time  for  the  operation,  and  would  much  prefer  to 
have  "  some  medicine  for  it." 

When  there  is  much  discharge,  the  ulcer  should  be 
frequently  dressed  (e.g.,  every  three  or  four  hoursj 
with  boracic  fomentations,  and  firmly  bandaged. 

When  the  discharge  has  lessened,  Unna's  'method 
may  be  employed.  Unna's  paste  consists  of  gelatin 
20  per  cent.,  zinc  oxide  20  per  cent.,  boric  acid  4  per 
cent.,  glycerine  32  per  cent.,  water  24  per  cent.  This 
is  melted  by  placing  the  vessel  containing  it  in  boiling 
water.  The  whole  limb  from  toe  to  just  below  the 
knee  is  well  washed  with  soap  and  water,  and  then 
with  I  in  1000  perchloride  lotion.  It  is  then  lightly 
sprinkled  with  boracic  powder,  as  a  preventive  of 
itching,  and  of  eczema.  The  limb  is  then  bandaged 
from  the  roots  of  the  toes  to  just  below  the  knee 
(excluding  the  heel  unless  the  ulcer  involves  it,  which 
it  rarely  does)  with  a  sterile  bandage.  This  should  be 
done  firmly,  and  as  far  as  possible  without  reverses. 
The  melted   Unna's  paste  is  then  painted  on  all  over 


ULCERATION  2g 

the  bandai^e.  A  layer  of  yauze  or  wood-wool  is 
applied  over  the  paste,  and  another  bandage  over  all. 
This  dressing  soon  sets  hard,  and  forms  a  very 
efficient  support. 

Eczema  around  the  ulcer  is  best  treated  by  calamine 
lotion   or   ichthyol   ointment. 

The  best  method  of  dealing  with  the  painful  spots 
in  an  "  irritable  ulcer  "  is  to  anaesthetize  the  patient 
and  thoroughly   scrape   the   surface   of  the   ulcer. 

It  may  be  by  no  means  easy  to  say  with  certainty 
that  a  given  ulcer  on  the  leg  is  not  syphilitic  in  nature. 
In  any  case  in  which  there  is  the  slightest  suspicion, 
potassium  iodide  gr.  xv  should  be  prescribed  three 
times  a  day  for  a  week,  in  addition  to  the  other  treat- 
ment. If  this  has  a  markedly  favourable  effect  on 
the  ulcer,   the   drug   should  be   continued. 

When  large  doses  of  iodides  are  prescribed,  the 
possil:)ility  of  iodisiu  must  not  be  forgotten.  lodism 
is  the  name  given  to  a  series  of  symptoms  due  to 
the  toxic  effect  of  the  drug.  The  symptoms  resemble 
those  of  a  common  cold,  vi;s.,  running  at  the  nose, 
sore  throat,  dull  headache,  especially  over  the  frontal 
sinus. 

Different  patients  vary  very  much  in  the  rapidity 
with  which  they  react  to  iodides. 

If  the  drug  be  discontinued  until  the  toxic  symptoms 
have  disappeared,  and  then  re-administered  in  smaller 
doses,  the  iodism  often  does  not  recommence.  It  is 
also  frequently  the  case  that  the  administration  of 
twice  the  quantity  of  iodide  will  put  an  end  to  the 
iodism. 

There  is  another  type  of  ulcer  which  falls  under  this 
heading,  namely,  the  trophic  ulcer,  as  it  is  probable 
that  the  actual  exciting  cause  is  some  slight  injury. 
The  trophic  ulcer,  however,  differs  from  those  already 
described,  in  that  it  is  dependent  on  an  important  un- 
derlying cause,  namely,  some  interference  with  the 
nerve  supply  of  the  part.  If  the  passage  of  impulses 
along  the  nerve  supplying  a  given  area  be  interrupted 
in  any  way,  that  area  is  very  prone  to  undergo  ulcera- 
tion. There  is  one  particular  type  of  ulcer  known 
as  the  perforating  tilcer  of  the  foot,  which  occurs  in 
certain  diseases  of  the  central  nervous  system,  notably 
tabes    dorsalis    (locomotor   ataxyj    and    syringomyelia. 


30  SURGERY     FOR     DENTAL     STUDENTS 

There  are  two  important  factors  involved.  First, 
there  is  a  diminished  sense  of  pain  in  the  part,  or 
sometimes  complete  anaesthesia;  and,  secondly,  there 
is  interference  with  the  trophic  function  of  the  nerves. 
Both  these  conditions  depend  upon  the  underlying- 
disease.  Owing  to  the  diminution  or  absence  of  the 
sense  of  pain,  the  gravity  of  an  injury  is  not  appre- 
ciated by  the  patient,  and  the  early  stages  may  thus 
escape  notice,  and  progress  untreated.  The  inter- 
ference with  the  trophic  function  lowers  the  vitality 
of  the  tissues,  rendering  them  less  able  to  combat  the 
ulceration. 

Perforating  ulcers  commonly  occur  under  the  head 
of  the  first  metatarsal  bone,  a  point  which  is  subjected 
to  considerable  pressure  in  walking.  As  the  name 
implies,  these  ulcers  penetrate  very  deeply,  the  ex- 
ternal opening  being  usually  quite  small.  The 
epithelium  tends  to  grow  down  the  sides  of  the  ulcer, 
and  thus  delay  healing.  Perforating  ulcers  are  usually 
quite  painless.  They  may  occur  in  other  situations, 
but  the   foot  is   most   commonly  affected. 

The  treatment,  of  course,  must  be  directed  chiefly 
towards  the  general  underlying  disease,  for  an  account 
of  which  a  text-book  on  medicine  should  be  consulted. 

The  local  condition  should  be  treated  by  absolute 
rest,  and  the  avoidance,  as  far  as  possible,  of  all  pres- 
sure. The  down  growth  of  epithelium,  mentioned 
above,  should  be  excised,  or  scraped  away  and 
cauterized,  and  any  unhealthy  parts  of  the  surface 
should  also  be  well  scraped.  Non-irritating  dressings, 
such  as  boracic  ointment,   should  be  applied. 

Prophylactic  (preventive)  treatment  is  of  paramount 
importance  in  all  conditions  in  which  trophic  ulcers 
are  likely  to  occur.  All  undue  pressure  must  be 
avoided,  and  great  care  taken  to  guard  against  injury. 
Burns  from  hot-water  bottles  in  parts  of  the  body 
devoid  of  sensation  are  a  common  cause  of  ulceration; 
great  care,  therefore,  should  be  exercised  in  this 
direction. 


CHAPTER  V. 

GANGRENE. 

By  gangrene  is  meant  the  death  of  a  considerable 
tract  of  tissue  en  bloc.  It  may  be  divided  into  two 
classes,  according  to  its  cause  :  — ■ 

{I)  Gangrene  dependent  upon  interference  with  the 
blood  supply  of  the  part. 

(2)  Gangrene  due  to  the  agency  of  micro-organisms, 
or  Septic  Gangrene. 

Gangrene  of  vascular  origin  may  be  either  dry  or 
moist.  This  depends  chiefly  iipon  the  condition  of  the 
part  immediately  previous  to  the  onset  of  the  gangrene. 
If  the  condition  is  due  to  a  gradual  narrowing  of  the 
lumen  of  the  arteries,  the  veins  being  unaffected,  there 
will  be  little  moisture  remaining  in  the  part  and  the 
gangrene  will  be  dry.  If,  on  the  other  hand,  the  flow 
in  both  arteries  and  veins  is  suddenly  blocked,  the  part 
will  be  full  of  blood,  and  moist  gangrene  will  result. 

Septic  gangrene  is  always  of  the  moist  variety.  If 
micro-organisms  gain  access  to  a  part  affected  w4th 
dry  gangrene  in  its  earlier  stages,  the  sepsis  will 
convert  it  into  moist  gangrene. 

Dry  Gangrene. — The  chief  varieties  of  dry  gangrene 
are  :  — 

(i)  Traumatic  either  from  direct  injury  to  the  main 
artery,  or  from  pressure,  say,  of  a  piece  of  fractured 
bone  upon  the  vessel.  It  may  also  result  from  severe 
burns;  from  the  action  of  corrosive  substances,  such 
as  strong  acids  {e.g.,  sulphuric  or  carbolic  acids);  or 
from  extensive  crushing  injuries  by  which  the  vitality 
of  the  part  is  destroyed.  The  application  of  carbolic 
acid,  even  in  w^eak  solutions  {e.g.,  an  ordinary  compres's 
of  I  in  40J,  for  any  length  of  time  is  very  liable  to 
be  followed  by  dry  gangrene,  especially  in  patients 
whose  general  strength  is  depressed. 

Frost-bite  may  cause  gangrene;  it  is  dependent  upon 
the  shrivelling  up  of  the  vessels  in  the  extreme  cold, 
and  may,  therefore,  be  classed  as  traumatic.      If  the 


32  SURGERY     FOR     DENTAL     STUDENTS 

cold  lasts  a  sufficient  time  the  arteries  themselves 
become  gangrenous;  when  this  has  occurred  the  subse- 
c[uent  warming  of  the  part  will  not  relieve  the  condition. 

(2)  Embolic  from  the  lodgment  of  an  embolus  in 
a  main  artery. 

(3)  Thrombotic  from  general  arterial  thrombosis. 

(4)  Senile,  due  to  gradual  narrowing  of  the  lumen  of 
the  arteries  from  chronic  arterial  disease,  ending  in 
complete  occlusion.  It  is  most  common  in  the  lower 
limbs. 

(5)  Idiopathic  (Raynaud's  disease),  generally  sup- 
posed to  be  due  to  spasm  of  the  arterioles  of  the  part, 
probably  a  vasomotor  phenomenon.  It  affects  most 
commonly  the  fingers  and  toes  of  children  or  young 
adults. 

(6)  Gangrene  due  to  poisoning  by  Ergot  is  rare  in 
this  country.  Ergot  is  a  fungus  which  infests  rye. 
The  disease,  ErgotistJt,  is  therefore  commoner  in  those 
countries  where  rye  bread  is  a  usual  article  of  diet. 
One  of  the  effects  of  ergot  is  powerful  contraction  of 
the  peripheral  vessels,  and  it  is  to  this  effect  that  the 
gangrene  is  due.  0 

(7)  Diabetic  gangrene  depends  upon  two  factors, 
partly  the  lowering  of  tissue  vitality  by  the  abnormal 
condition  of  the  blood,  and  partly  the  endarteritis  which 
is  so  often  associated  with  diabetes. 

Symptdms  and  Signs.  — There  are  certain  clinical 
phenomena  which  are  common  to  all  forms  of  gan- 
grene, viz.  :  — 

(i)  Cessation  of  the  arterial  pulse. 

(2)  Fall  of  temperature  in  the  affected  part. 

(3)  Anesthesia  of  the  part.  This  anaesthesia  is 
apparently  not  complete,  because  referred  pain  from 
the  boundary  of  healthy  and  diseased  tissue  often  gives 
rise  to  an  impression  of  pain  in  the  diseased  part, 
thoui^h  the  patient  is  unable  to  appreciate  irritation  in 
the  affected  area. 

(4)  Loss  of  function  in  the  part. 

(5)  Change  of  colour,  which  varies  according  to  the 
type  of  gangrene  present. 

The  clinical  history  of  simple  dry  gangrene  varies 
according  to  the  rapidity  of  onset. 

When  the  onset  is  acute,  as  in  gangrene  due  to 
embolus,  injury,  and  sometimes  in  Raynaud's  disease. 


GANGRENE  33 

there  is  usually  severe  neuralgic  pain  at  the  commence- 
ment of  the  disease.  The  part  becomes  cold,  white, 
and  pulseless.  The  colour  changes  to  bluish,  and  later 
to  dark  brown  or  black.  The  skin  wrinkles,  and 
becomes  hard  and  dry.  This  is  most  marked  at  the 
periphery. 

Where  it  joins  the  healthy  tissue  the  gangrenous 
part  is  rather  redder  and  slightly  oedematous.  At  the 
margin  of  this  red  area  a  bright  red  line  appears. 
This  is  the  line  of  demarcation,  and  marks  the  point 
at  which  Nature,  if  left  to  herself,  will  separate  the 
dead  from  the  living  tissue.  This  separation  is  brought 
about  by  a  simple  process  of  ulceration,  which  pro- 
gresses until  the  gangrenous  part  is  completely  cast 
off.  The  ulcerated  surface  then  behaves  like  a  simple 
healing  ulcer.  The  part  cast  off  will  often  be  found 
to  be  completely  mummified. 

The  process  described  only  occurs  in  dry  gangrene 
which  has  been  kept  aseptic. 

If  the  gangrene  be  moist,  the  part  does  not  become 
mummified.  The  tissues  rapidly  decompose;  the  skin 
becomes  bluish  and  peels  off;  oft'ensive  gases  are 
formed,  and  the  part  becomes  oedematous.  A  line  of 
dc7nar cation  is  formed  as  described  above,  but  it  is 
very  rare  that  separation  of  the  part  is  brought  about, 
as  toxic  substances  formed  by  the  decomposing  tissues 
are  absorbed  into  the  system,  and  general  sepsis 
almost  invariably  occurs.  Constitutional  symptoms, 
such  as  fever,  asthenia,  &c.,  are  more  marked  in  this 
type,   and  fatal  termination  unfortunately  common. 

Treatment. — In  the  case  of  dry  gangrene  strenuous 
efforts  must  be  made  to  maintain  asepsis.  The  part 
must  be  carefully  purified;  if  it  involves  a  limb,  the 
nails  should  be  cut  and  carefully  cleansed.  The  part 
must  then  be  covered  with  a  dry  aseptic  dressing.  All 
moisture  must  be  avoided  as  far  as  possible.  If  no 
sepsis  occurs,  the  line  of  demarcation  will  form  as 
described  above.  Amputation  should  then  be  per- 
formed, sufficiently  far  above  the  line  of  demarcation 
to  ensure  that  the  amputation  flaps  are  properly 
supplied  with  blood.  Attention  must  also  be  paid  to 
the  usefulness  of  the  stump.  It  may  be  necessary  to 
sacrifice  some  healthy  tissue  in  order  to  obtain  a 
serviceable  limb. 
3 


34  SURGERY    FOR    DENTAL     STUDENTS 

In  old  patients  with  extensive  arterial  disease  the 
question  of  amputation  is  a  very  difficult  one  to  decide, 
and  each  individual  case  must  be  considered  on  its 
own  merits.  Space  forbids  us  to  discuss  this  question 
fully.  Suffice  it  to  say  that  in  these  cases  the  vitality 
of  the  limb  may  be  so  depressed,  and  the  circulation 
so  much  impeded  by  arterial  disease,  that  if  amputation 
be  performed,  even  far  above  the  line  of  demarcation, 
the  injury  of  the  operation  may  be  sufficient  to  deter- 
mine the  onset  of  gangrene  in  the  flaps.  In  these 
cases  the  only  treatment  is  to  keep  the  part  aseptic 
and  to  husband  the  strength  of  the  patient. 

In  moist  gangrene,  and  when  sepsis  has  occurred, 
immediate  amputation  must  be  performed,  well  above 
the  seat  of  the  disease. 

The  following  varieties  of  Septic  gangrene  in  which 
micro-organisms  form  the  primary  cause  of  the  con- 
dition are  usually  described  :  — • 

(1)  Acute  Spreading  Traumatic  Gangrene.— This 
condition  is  extremely  grave,  and  commonly  terminates 
fatally.  It  may  occur  as  a  sequela  of  any  severe  injury, 
especially  compound  fracture.  It  differs  from  the  types 
of  gangrene  above  described  in  its  tendency  to  spread 
in  all  directions.  It  is  not  wholly  governed  by  the 
position  of  the  injury,  but  may  spread  up  the  limb, 
above  the  lesion. 

It  commences  at  the  edges  of  the  wound,  not  at 
the  periphery  of  the  limb.  The  skin  becomes  purple, 
gradually  darkening  to  black.  The  disease  spreads 
very  rapidly,  and  there  is  much  oedema;  decomposition 
soon  occurs.  Marked  Surgical  Emphysema  (air  in  the 
tissues)  is  present,  due  in  most  cases  to  the  activity 
of  Bacillus  oedematis  m-aligni.  As  the  disease  spreads 
rapidly  in  all  directions,  it  will  be  clear  that  no  line 
of  demarcation  will  form.  Constitutional  symptoms 
are  remarkable  in  that  there  is,  as  a  rule,  profound 
asthenia,  associated  with  normal,  or  even  subnormal, 
temperature. 

The  only  hope  of  saving  the  life  of  the  patient  is 
immediate  amputation  well  above  the  site  of  disease  ; 
but  recurrence  of  gangrene  in  the  stump  is  unfortun- 
ately common. 

(2)  Hospital  Gangrene.  -This  term  is  applied  to 
rapidly  spreading  gangrene  affecting  operation  wounds. 


GANGRENE  35 

It  is  practically  unknown  since  the  introduction  of 
antiseptic  methods. 

(3)  Phagedsena  is  a  type  of  gangrenous  ulceration 
which  sometimes  affects  venereal  sores.  The  term  has 
also  been  used  as  identical  with  hospital  gangrene. 

(5)  Cancrum  oris  is  a  form  of  gangrenous  ulceration 
occurring  in  early  childhood.  It  is  more  common  in 
town  than  country,  and  is  almost  entirely  confined  to 
the  children  of  the  poor.  It  is  often  a  sequela  of  one 
of  the  acute  specific  fevers,  especially  measles.  It 
will  be  seen,  therefore,  that  conditions  which  tend  to 
lower  tissue  vitality  act  as  predisposing  causes. 

The  actual  exciting  cause  of  the  disease  is  micro- 
organic.  No  specific  organism  has  been  isolated,  and 
it  is  probable  that  the  various  organisms  normally 
present  in  the  mouth,  including  Streptococcus  pyo- 
genes, are  jointly  responsible.  They  gain  access  first 
through  some  slight  abrasion  of  the  buccal  mucous 
membrane,  either  on  the  lips,  gums,  or  cheeks,  or 
occasionally  through  the  socket  of  a  tooth.  From  this 
point  of  entrance  the  disease  spreads  rapidly  and  is 
very  destructive.  Large  portions  of  cheek  or  gum 
may  be  destroyed;  necrosis  of  the  jaw  may  occur. 

The  discharge  is  extremely  foul  and  toxic,  and  is 
generally  swallowed  continuously,  frequently  giving 
rise  to  septic  broncho-pneumonia  or  even  septicaemia 
(q.v.),  either  of  which  complications  may  rapidly  prove 
fatal.  A  fatal  result  may  occur  without  these  compli- 
cations, from  exhaustion  and  the  toxic  effects  of  the 
disease.  Pyaemia  (q.v.)  may  occur  from  implication 
of  a  large  vein,  often  the  facial  vein. 

In  the  early  stages  the  temperature  is  usually  con- 
siderably raised  (103°  or  104°),  and  rigors  are  often 
present.  At  the  end  the  temperature  usually  falls  beloAv 
normal,  and  coma  supervenes. 

Treatment  consists  in  the  removal  of  all  traces  of 
diseased  tissue  under  an  anaesthetic. 

Noma  Yulvse  is  a  similar  condition  affecting  the 
vulva  and  surrounding  parts  in  a  similar  type  of 
patient. 

A  boil  or  furuncle  is  a  staphylococcic  inflammation 
of  the  skin  and  subcutaneous  tissue,  which  commences 
in  a  hair  follicle. 

At  first  a  painful  reddish  nodule  is   formed   in  the 


36  SURGERY     FOR    DENTAL     STUDENTS 

skin.  The  central  part  becomes  gangrenous.  A 
pustule  then  forms,  which  bursts,  the  central  gangren- 
ous portion  being  separated  and  discharged  as  a 
slough.  Boils  are  generally  multiple,  the  whole  con- 
dition being  known  as  Furunculosis.  Constitutional 
disturbances  predispose  to  the  condition. 

Furunculosis  is  more  common  in  men  than  women, 
the  patients  usually  being  young  adults.  The  most 
frequent  situations  for  the  disease  are  the  back  of  the 
neck  and  shoulders,  and  the  buttocks. 

Treatment  consists  in  incising  the  boils,  with  anti- 
septic precautions,  when  the  pustular  stage  is  reached, 
applying  pure  carbolic  acid,  and  dressing  aseptically. 
Any  general  condition  which  may  be  present  must  also 
be  treated. 

The  administration  of  calcium  carbide  J  gr.,  in  pill 
form,  three  times  a  day  is  often  of  value. 

A  carbuncle  is  also  a  staphylococcic  infection.  It 
involves  the  subcutaneous  tissue  primarily,  reaching 
the  skin  later.  (The  reverse  is  the  case  with  a  boil.) 
Carbuncles  are  usually  single,  and  are  much  larger  in 
size  than  boils.  They  occur  in  similar  situations  in  a 
similar  class  of  patient. 

Local  treatment  consists  in  making  a  free  incision, 
and  scraping  away  all  diseased  tissue  under  an  anaes- 
thetic, and  applying  pure  carbolic  acid.  Antiseptic 
dressings  are  then  required. 

General  treatment  may  be  required,  if  the  general 
conditions  demand  it.  For  example,  diabetes  is  a 
common  predisposing  cause  both  of  carbuncles  and 
boils,  and  if  present  will,  of  course,  require  to  be  dealt 
with.  In  this  connection  it  should  be  noted  that  a 
transient  glycosuria  (sugar  in  the  urine)  may  occur 
when  carbuncles  are  present,  disappearing  as  soon  as 
they  have  been  dealt  with.  This  must  not  be  mistaken 
for  diabetes  mellitus. 

Vaccines  have  been  used,  often  with  great  benefit, 
in  the  treatment  both  of  carbuncles  and  of  boils. 


CHAPTER  VI. 
WOUNDS. 

A  wound  is  an  injury  which  involves  solution  of 
continuity  of  the  skin  or  mucous  membrane. 

An  injury  to  subcutaneous  tissue,  the  skin  or  mucous 
membrane  remaining  intact,  is  called  a  contusion. 

Both  conditions  result  from  the  application  of 
external  violence,  the  kind  of  injury  depending  upon 
the  amount  of  force  exercised  and  the  nature  of  the 
instrument  employed. 

A  contusion  is  caused  by  a  blunt  instrument,  when 
the  skin  is  not  broken. 

The  clinical  signs  of  a  contusion  are :  pain,  subcu- 
taneous haemorrhage,  and  swelling.  In  slight  cases 
the  haemorrhages  are  minute  and  discrete,  scattered 
through  the  subcutaneous  tissues. 

In  more  severe  cases  extravasation  of  blood  occurs 
under  the  skin,  resulting  in  discoloration.  At  first,  the 
colour  of  the  skin  is  bluish-black,  gradually  it  passes 
through  brown  to  yellow,  and  so  disappears.  The 
intensity  of  the  discoloration  varies  in  different  situa- 
tions. Where  the  tissues  are  lax  there  is  little  to 
interfere  with  the  dispersion  of  the  blood,  and  therefore 
much  discoloration  occurs.  In  situations  where  dense 
fasciae  are  present  and  the  haemorrhage  has  occurred 
below  them,  there  may  be  little  or  no  discoloration, 
or  it  may  take  longer  than  usual  to  develop.  This 
subcutaneous  haemorrhage  is  known  as  a  bruise  or 
ecchyniosis.  The  swelling  also  varies  considerably  in 
amount  and  is  governed  by  similar  factors. 

If  the  hemorrhage  takes  place  into  a  space  in  which 
it  is  confined  by  definite  boundaries,  such  as,  for 
instance,  the  tunica  vaginalis,  or  beneath  the  aponeuro- 
sis oi  the  occipito-frontalis  muscle,  it  collects  there, 
forming  a  fluctuating  swelling  known  as  a  haematoma. 
This  may  closely  resemble  an  abscess,  but  the  history 
of  injury  and  absence  of  signs  of  inflammation  usually 
suffice  to  determine  the  nature  of  the  condition.    Later, 


38  SURGERY     FOR    DENTAL     STUDENTS 

a  deposit  of  fibrin  occurs  in  the  blood  in  hsematoma. 
The  fluid  is  usually  completely  absorbed.  The  fibrin 
may  also  be  absorbed  entirely.  In  other  cases  it  may 
persist  as  a  fibrous  tumour.  In  rare  cases,  after  the 
partial  absorption  of  both  solid  and  fluid  contents  of 
the  haematoma,  a  definite  capsule  containing  serous 
fluid  persists. 

The  treatment  of  contusions  consists  in  the  appli- 
cation of  evaporating  lotions,  e.g.,  lotio  pluinbi. 
Tincture  of  arnica  is  also  often  used.  In  very  early 
stages,  before  the  discoloration  has  made  its  appear- 
ance, relief  of  pain  may  be  obtained  by  fomentation. 
Where  a  hsematoma  exists  in  very  tense  tissues,  the 
pain  caused  may  be  very  great.  In  these  cases  it  may 
l3e  permissible  to  puncture  it,  squeeze  out  the  contents, 
and  apply  pressure  to  prevent  further  haemorrhage, 
great  care  being*  taken  to  maintain  asepsis.  The  act 
of  puncture  converts  the  contusion  into  a  wound  and 
thus  introduces  the  necessity  for  aseptic  treatment. 

In  very  severe  cases  consitutional  symptoms  may  be 
present.  They  must  be  dealt  with  on  the  general  lines 
indicated  on  p.  53. 

There  are  three  chief  varieties  of  wounds  :  — 

(i)  Incised;  (2)  Punctured;  (3)  Lacerated. 

(i)  An  incised  wound  is  one  made  with  a  sharp, 
cutting  instrument.  The  most  typical  example  is  an 
operation  wound.  It  is  cleanly  cut,  and  there  is  little 
or  no  bruising  of  surrounding  parts.  The  haemorrhage 
is  usually  profuse,  depending,  of  course,  upon  the 
position  of  the  lesion  and  the  size  of  the  vessels 
injured. 

Treatment. — If  an  important  organ,  such  as  stomach 
or  bowel,  &c.,  is  included  in  the  wound,  special 
operative  interference  may  be  necessary,  into  the 
details  of  which  space  does  not  permit  us  to  enter. 
If  no  important  organ  is  wounded,  the  first  essential 
is  to  arrest  the  haemorrhage.  In  slight  cases  this  end 
may  be  attained  by  exposing  the  part  to  any  extreme 
of  temperature,  either  heat  or  cold.  Either  ice-cold 
water  or  water  as  hot  as  the  patient  can  bear  should 
be  employed.  Warm  water  should  not  be  used,  as  it 
does  not  tend  to  arrest  the  haemorrhage.  If  this 
method  fails  our  next  sheet-anchor  is  pressure  in  some 
form  or  other.  SHght  cases  can  usually  be  arrested 
by  the  application  of  a  firmly-bandaged  dressing. 


WOUNDS  39 

There  are  certain  drugs  which,  when  apphed  locally, 
tend  to  arrest  haemorrhage.  These  drugs  are  known 
as  Styptics.  They  are  only  of  value  in  cases  of  slight 
haemorrhage,  and  even  in  slight  cases  are  of  less 
efficacy  than  pressure  if  the  wound  is  in  such  a  position 
that  firm  pressure  can  be  applied.  Their  scope  is  con- 
sequently limited,  but  in  some  situations  they  are  of 
considerable  value.  This  is  the  case  when  dealing  with 
haemorrhage  after  the  extraction  of  a  tooth.  It  is 
true  that  pressure  can  be  applied  to  a  tooth-socket  by 
means  of  a  firm  plug  of  cotton-wool,  retained  in  place 
if  necessary  by  a  cork,  or  an  ansesthetist's  gag.  It  is 
difficult  to  apply  very  firm  pressure  with  plugs  of 
cotton-wool  alone,  and  the  plugs  frequently  become 
dislodged.  Pressure  by  means  of  a  cork  may  be 
painful.  Styptic  drugs,  therefore,  are  of  value  in  these 
cases. 

Styptics  may  roughly  be  divided  into  two  classes, 
according  to  their  mode  of  action  :  — 

(i)  Drugs  which  cause  a  local  cojistriction  of  the 
blood-vessels. 

There  is  only  one  drug"  in  constant  use  which  acts 
in  this  way,  namely,  Adrenalin.  This  substance  is 
one  of  the  most  valuable  styptics  we  have.  It  is  a  very 
powerful  drug,  and  is  used  in  very  weak  solution,  viz., 
I  in  1000.  It  should  be  noted  that  adrenalin  solutions 
rapidly  deteriorate  under  the  influence  of  light  and 
air,  and  therefore  should  be  freshly  prepared,  if 
possible,  and  kept  in  the  dark  in  brown  glass  bottles. 
The  drug  should  be  applied  to  the  bleeding  area  on  lint 
or  cotton-wool  and  bandaged.  When  the  haemor- 
rhage follows  the  extraction  of  a  tooth,  the  socket 
should  be  plugged  with  pledgets  of  wool  soaked  in  the 
adrenalin  solution.  It  should  be  noted  that  pressure 
acts  in  the  same  way  as  adrenalin,  namely,  by  inducing 
a  local  constriction  of  the  blood-vessels. 

(2)  Drugs  which  induce  coagulation  of  the  protein 
in  the  blood. 

There  are  a  large  number  of  drugs  included  under 
this  heading  which  have  earned  great  reputations, 
sometimes  deserved  and  sometimes  undeserved. 
Tannic  Acid  is,  perhaps,  the  best  known.  It  may  be 
applied  in  powder  upon  cotton-wool.  Several  other 
drugs  are  used  which  derive  their  styptic  value  solely 


40  SURGERY    FOR    DENTAL     STUDENTS 

from  the  fact  that  they  contain  a  percentage  of  tannic 
acid,  e.g.,  HamameHs,  Krameria,  &c.  It  stands  to 
reason  that  pure  tannic  acid  wih  act  more  rapidly  and 
efficiently  than  some  drug  containing  only  a  percentage 
of  the  acid,  and  therefore  these  other  substances  may 
be  discarded  in  favour  of  the  pure  acid. 

Solid  silver  nitrate  is  another  useful  styptic,  as  also 
is  powdered  alum. 

Certain  compounds  of  Iron  have  a  great  reputation 
as  styptics,  notably,  ferric  chloride.  The  liquor  ferri 
perchloride  is  the  preparation  usually  employed.  The 
use  of  iron  salts  for  this  purpose  cannot  be  too 
strongly  condemned.  Though  large  doses  of  iron  may 
be  given  by  the  mouth  without  any  untoward  results, 
iron,  when  it  reaches  the  blood-stream,  acts  as  a 
virulent  poison.  (When  given  by  the  mouth  only 
minute  quantities  of  the  drug  are  absorbed.)  It  will 
be  clear  that  if  iron  is  applied  to  an  open  wound  with 
a  view  of  arresting  haemorrhage,  there  is  considerable 
danger  of  a  portion  of  the  drug  being  absorbed  into 
the  circulation.  Death  has  occurred  on  more  than  one 
occasion  from  the  application  of  perchloride  of  iron 
to  the  uterus  in  order  to  stop  post-partum  haemorrhage. 
Its  value  as  a  styptic  is  by  no  means  sufficient  to 
warrant  incurring  such  a  grave  risk. 

The  use  of  fibrin  ferment  in  haemophilia  is  discussed 
on  p.  105. 

Another  drug  which  must  be  mentioned  in  this  con- 
nection is  calciufn.  Opinions  as  regards  its  efiicacy 
are  divided.  As  is  almost  always  the  case  when  differ- 
ences of  opinion  exist  among  the  medical  faculty,  there 
are  people  on  both  sides  who  go  very  much  too  far. 
In  their  attempts  to  pour  contempt  upon  their 
opponents  they  make,  in  the  heat  of  the  moment, 
exaggerated  statements  which  they  do  not  really 
believe,  but  these  statements  once  made  must  be  fought 
for  through  thick  and  thin,  and  often  through  the 
medium  of  a  text-book  by  their  author  they  pass  into 
current  teaching. 

It  is  always  better  in  text-books  to  steer  a  middle 
course.  And  it  can  safely  be  said  that  there  are  cases 
of  haemorrhage  in  which  calcium  is  of  value,  and  there 
are  also  cases  in  which  it  is  of  no  value.  In  dealing 
with  the   disease,    haemophilia,    in   Chapter   XIII,    the 


i 


WOUNDS  41 

student's  attention  will  be  called  to  the  fact  that  the 
blood    in    the    haemophilic   patient    contains    plenty    of 
calcium,  and  that   its   failure   to   coagulate   is  due   to 
a  scarcity  of  fibrin  ferment.     This  is  an  experimental 
fact,  and  must  be  accepted  as  such.     It  is  also  said  that 
haemophilia  is  a  disease  which  occurs  almost  invariably 
in  males;  some  authorities  deny  that  females  are  ever 
affected.     This  may  or  may  not  be  true.     But  the  fact 
remains  that  there  does  exist  a  condition  which  attacks 
females    certainly    as    often    if    not    more    often    than 
males   in   which   most   dangerous   haemorrhage   occurs 
from  the  most  trivial  wounds.     Many  such  cases  have 
occurred  in  the  author's  personal  experience,  in  which 
the  patients   (ahvays  females)  have  been  at  the  point 
of  death  from   haemorrhage   following   the    extraction 
of  a  tooth.     And  in  these  cases  the  administration  of 
10  gr.   of  calcium  lactate   three   times   a   day  for  five 
days  before  operation  has  been  completely  successful, 
the    operation    being  'conducted   without    any    severe 
subsequent  haemorrhage.     In  one  particular  case  under 
the  author's  care,   the  patient  some  years  after  con- 
sulted another  dental  surgeon,  who,  being  unaware  of 
her  previous   history,    omitted  the   calcium  treatment. 
The  result  was  that  the  patient  again  very  nearly  died 
of  haemorrhage  after  the   operation.       Possibly  these 
cases  are  not  examples   of  haemophilia,   but  they  are 
none  the  less   serious,   and  must  always   be   borne  in 
mind. 

Another  type   in  which  there  is   great  tendency  to 

uncontrollable    haemorrhage    is    the    deeply    jaundiced 

patient.     In  these  cases,  also,  calcium  is  of  great  value. 

Calcium  has  also  been  used  as  a  local  styptic,   but 

does  not  appear  to  be  of  great  value. 

In  more  severe  cases,  where  a  larger  artery  is 
wounded,  it  will  be  necessary  temporarily  to  stop  the 
bleeding  by  compressing  the  main  artery  on  the 
proximal  side  of  the  injury,  either  with  the  fingers  or 
by  the  application  of  a  tourniquet.  The  haemorrhage 
being  thus  temporarily  controlled,  the  cut  ends  of  the 
injured  vessel  should  be  sought,  seized  with  Spencer 
Wells's  forceps,  and  ligatured. 

Small  arteries,  if  completely  divided,  usually  retract 
and  stop  bleeding  without  interference,  but  if  only 
partially  divided  the}^  cannot  retract,  and  consequently 


42  SURGERY    FOR    DENTAL     STUDENTS 

continue  to  bleed.  Tlie  treatment  of  sucli  a  case 
clearly  is  to  divide  the  injured  vessel  completely. 

The  second  essential  in  the  treatment  is  to  cleanse 
the  wound.  The  amount  of  cleansing  required  will 
depend  to  some  extent  upon  the  nature  and  cleanliness 
of  the  instrument  by  which  the  injury  was  inflicted. 
But  in  any  case  the  wound  should  be  thoroughly 
washed  with  some  antiseptic  lotion  (e.g.,  carbolic 
I  in  40),  all  visible  particles  of  dirt  being  removed. 

The  third  point  should,  perhaps,  have  been  put 
second,  namely,  constitutional  treatment.  This  only 
requires  attention  in  severe  cases,  but  then  it  is  of 
paramount  importance.  If  much  blood  has  been  lost 
the  patient  may  be  collapsed,  and  at  the  point  of  death 
from  actual  exhaustion.  As  soon  as  the  haemorrhage 
has  been  arrested,  at  least  temporarily,  attention  must 
be  paid  to  constitutional  treatment.  It  is  not  desir- 
able in  the  early  stages  to  give  stimulants,  such  as 
strychnine,  to  any  great  extent.  The  natural  means 
of  arresting  haemorrhage  is  by  the  formation  of  a 
clot.  If  stimulants  be  given  there  is  a  danger  that 
the  clot  may  be  disturbed  by  the  increased  blood- 
pressure,  and  the  haemorrhage  break  out  afresh.  In 
these  cases  of  collapse,  due  to  profuse  haemorrhage, 
the  best  drug  to  give  is  opium  in  doses  of  half  a  grain 
frequently  repeated,  say,  every  hour  for  five  hours. 
In  very  severe  cases  a  saline  infusion  may  be  necessary. 
The  method  of  administration  of  a  saline  infusion  is 
as  follows  :  — 

One  to  two  pints  of  normal  saline  solution  is  infused 
under  the  skin,  by  means  of  a  hollow  needle  connected 
to  a  glass  vessel  by  rubber  tubing.  This  whole 
apparatus  must  be  boiled  before  use,  as  also  is  the 
saline  solution.  The  groins  are  usually  chosen  as  the 
site  of  infusion.  The  rate  of  flow  can  be  regulated  by 
raising  or  lowering  the  glass  vessel.  The  feet  should 
be  slightly  raised  above  the  level  of  the  head  and  hot 
bottles  applied  to  them. 

Having  arrested  the  haemorrhage,  rendered  the 
wound  aseptic,  and  treated  the  collapse,  if  present,  the 
surgeon  must  turn  his  attention  to  bringing  the  edges 
of  the  wound  together.  If  the  wound  is  quite  small, 
this  may  be  effected  simply  by  the  pressure  of  a  dress- 
ing.    Otherwise,  it  will  be -necessary  to  insert  one  or 


WOUNDS  43 

more  stitcRes,  as  may  be  required.  Sufficient  stitches 
must  be  used  to  avoid  undue  tension  on  any  one  of 
them.  To  ensure  .rapid  heahng,  and  render  the  subse- 
quent scar  as  small  as  possible,  it  is  very  important 
that  the  edges  of  the  wound  should  be  in  quite  close 
apposition.  If  sepsis  is  present,  or  if  it  is  doubtful 
whether  the  haemorrhage  has  been  completely  arrested, 
the  insertion  of  a  rubber  drainage  tube  may  be 
required.  It  should  be  quite  small  {e.g.,  the  size  of  a 
No.  8  catheter),  so  that  the  edges  of  the  wound  are 
not  separated  more  than  is  necessary.  It  can  usually 
be  removed  after  twenty-four  hours.  After  the  inser- 
tion of  the  tube  an  aseptic  dressing  is  applied. 
Complete  rest  of  the  injured  part  should  be  enjoined. 

(2)  A  punctured  wound  is  one  made  with  a  sharp, 
pointed  instrument;  it  is  of  such  a  shape  that  the  depth 
from  the  surface  to  the  bottom  of  the  wound  is  its 
longest  dimension.  It  may  be  caused  by  a  variety  of 
instruments,  from  a  tin-tack  or  a  hat-pin,  to  a  dagger 
or  a  bayonet. 

The  general  principles  governing  the  treatment  of 
punctured  wounds  are  exactly  similar  to  those  already 
described  under  incised  wounds  (q.z'-).  An  accident 
more  liable  to  occur  in  a  punctured  than  an  incised 
wound  is  that  the  point  of  the  instrument  may  break 
off  in  the  wound.  The  fragment  must  be  at  once 
removed;  X-rays  may  be  required  in  order  to  locate  it. 

(3)  A  lacerated  or  contused  wound  is  made  by  a 
heavy,  blunt  instrument,  such  as  a  cart-wheel,  a  stone, 
(S:c.  It  is  irregular  in  shape,  with  much  bruising  of 
the  surrounding  parts.  It  must  be  remembered,  how- 
ever, that  blunt  instruments  frequently  cause  quite  a 
clean  cut. 

Treatment  will  be  on  the  same  principles  as  those 
described  above.  The  danger  of  sepsis  is  usually 
greater,  the  task  of  uniting  the  edges  of  the  wound 
more  difficult,  and  the  constitutional  disturbance 
frequently  grave. 

In  injuries  which  involve  the  severe  crushing  of  a 
limb,  the  question  of  amputation  will  have  to  be  con- 
sidered. In  a  hand-book  of  this  type  it  is  impossible 
to  lay  down  any  rule  with  regard  to  this  question. 
Each  particular  case  must  be  decided  upon  its  own 
merits,   having  regard  to  the  age  and  vitality  of  the 


44  SURGERY    FOR    DENTAL     STUDENTS 

patient;  the  extent  of  the  injury,  especially  in  its 
relation  to  the  blood  supply;  and  the  presence  or 
absence  of  sepsis. 

Gun-shot  and  reYolver-shot  wounds  are  usually 
placed  in  a  class  by  themselves.  They  vary  in  size  and 
shape  according  to  the  variety  of  bullet  employed. 
Treatment  does  not  differ  in  principle  from  that  of 
wounds  generally.  Obviously  the  bullet,  if  present, 
must,  if  possible,  be  removed. 

One  or  two  special  forms  of  wounds  must  be  dis- 
cussed separately:  — 

Wounds  due  to  the  Bites  of  Poisonous  Snakes. — 
The  surgeon's  energies  in  these  cases  are  directed 
towards  preventing  the  virus  introduced  by  the  snake 
into  the  local  lesion,  from  reaching  the  general  circu- 
lation. A  ligature  is  first  tied  tightly  round  the  limb, 
above  the  bite.  The  wound  is  then  enlarged  by  free 
incisions  to  induce  haemorrhage;  if  necessary,  a 
cupping  glass  may  be  applied.  A  speedy  outflow  of 
blood  tends  to  remove  the  virus.  When  the  immediate 
danger  is  passed,  the  wound  is  treated  according  to 
general  principles.  • 

Dog  Bites.  — As  a  rule,  there  are  no  particular 
reasons  for  suspecting  the  dog  to  be  rabid.  The 
application  of  solid  silver  nitrate  to  the  wound  will 
suffice.  If  there  is  genuine  fear  that  the  dog  suffered 
from  rabies,  the  edges  of  the  wound  should  be  freely 
excised  under  an  anaesthetic.  It  may  be  noted  that  the 
dog  should  be  preserved  until  such  time  as  the  nature 
of  his  disease  is  fully  disclosed. 

Burns  and  Scalds.  — -Burns  and  scalds  are  injuries 
due  to  the  application  of  heat.  Dry  heat  causes  a 
burn,  while  moist  heat  results  in  a  scald.  There 
is  no  great  difference  in  the  clinical  manifestations  of 
the  two  types  of  injury,  and  they  may  conveniently 
be  discussed  together. 

Six  different  degrees  of  injury  have  been  described, 
according  to  the  depth  of  the  lesion. 

First  Degree. — The  skin  is  simply  scorched;  no 
destruction  of  tissue  takes  place.  ; 

Second  Degree. — Vesication  takes  place,  that  is  to 
say,  an  exudation  of  fluid  occurs  superficial  to  the 
cutis  vera  and  beneath  the  cuticle;  the  cuticle  is  thus 
raised,  forming  a  blister. 


WOUNDS  45 

Third  Degree. — The  cuticle  and  part  of  the  cutis  vera 
are  destroyed,  laying  bare  the  terminations  of  the  cuta- 
neous nerves. 

Fourth  Degree. — The  whole  integument  is  destroyed, 
including  all  the  glands  of  the  skin. 

Fifth  Degree. — The  injury  involves  the  muscles. 

Sixth  Degree. — All  the  tissues,  including  the  bone, 
may  be  involved. 

The  pathological  processes  which  occur  are  those  of 
inflammation  and,  if  recovery  supervenes,  subsequent 
repair.  The  intensity  of  the  inflammation  varies 
according  to  the  severity  of  the  injury.  The  severer 
degrees  of  burns  are  almost  invariably  accompanied  by 
septic  infection.  This  is  due  to  various  factors;  the 
skin  is  rarely  clean  in  a  surgical  sense,  and  if  burnt 
clothing,  &c.,  is  involved  in  the  wound,  the  probability 
of  infection  is  increased.  The  vitality  of  the  part  is 
also  depressed  by  the  injury,  rendering  the  tissues  less 
able  to  combat  a  possible  bacterial  invasion. 

The  clinical  signs  are  local  and  general. 

The  local  signs  in  a  burn  or  scald  of  the  first  degree 
are  those  described  under  inflammation,  vis.,  pain, 
redness,  heat,  swelling  (usually  slight  in  amount),  and 
impairment  of  function.  The  danger  of  sepsis  is  not 
so  great  as  in  the  severer  degrees.  While  healing  is 
taking  place,  there  is  usually  a  certain  amount  of 
desquamation. 

In  an  injury  of  the  second  degree,  in  addition  to  these 
signs,  vesication  occurs. 

When  the  injury  is  of  the  third  degree,  the  inflam- 
matory signs  are  again  present;  but  as  the  nerves  are 
laid  bare  the  pain  is  very  much  more  intense,  and  part 
of  the  true  skin  being  destroyed,  the  danger  of  sepsis 
is  greater.  Healing  occurs  by  granulation,  and  is 
generally  rapid.  As  some  of  the  glands  remain  intact, 
the  formation  of  new  epithelium  begins  around  these 
glands  as  well  as  at  the  edges  of  the  lesion.  There  is 
very  little  tendency  to  subsequent  fibrous  contraction. 

In  the  more  severe  degrees  the  inflammation  is  more 
intense,  there  is  greater  danger  of  sepsis,  and  healing 
takes  place  much  less  quickly.  The  pain  in  this  case 
is  commonly  less  severe  than  in  an  injury  of  the  third 
degree. 

The  whole  of  the  true  skin  having  been  destroyed, 


46  SURGERY     FOR     DENTAL     STUDENTS 

a  good  deal  of  libroUvS  tissue  is  formed  in  the  process  of 
repair,  and  there  is  often  considerable  contraction  in 
the  scar. 

The  ge7ieral  signs  are  those  of  shock.  The  severity 
of  the  shock  depends  more  upon  the  superficial  extent 
than  upon  the  depth  of  the  injury.  In  severe  cases  the 
shock  lasts  about  two  days.  This  is  followed  by  a  con- 
dition of  slight  fever  and  general  weakness,  lasting  a 
variable  time.  The  severity  of  the  febrile  symptoms 
depends  mainly  upon  the  degree  of  sepsis  which  has 
occurred.  Inflammation  of  various  organs  may  occur 
during  this  stage,  the  lungs,  pleura,  meninges  or  diges- 
tive system  sometimes  being  affected. 

One  complication  which  is  characteristic,  though 
happily  rare,  is  ulceration  of  the  duodenum.  The  ulcers 
do  not  differ  clinically  or  pathologically  from  the  usual 
form  of  duodenal  ulcer. 

The  prognosis  depends  chiefly  upon  the  degree  of 
shock,  the  position  of  the  injury  (it  is  less  grave  if 
the  limbs  are  involved  than  the  trunk),  the  previous 
condition  and  age  of  the  patient,  and  the  degree  of 
sepsis  present.  Death  may  occur  in  early  stages  from 
shock  or  collapse;  later  on  it  may  result  from  sepsis 
and  consequent  toxemia,  or  from  any  of  the  complica- 
tions above  mentioned,  e.g.,  duodenal  ulcer. 

Treatment. — The  first  essential  is  to  treat  the  shock, 
if  present.  The  patient  should  be  kept  warm  with  hot 
blankets;  hot-water  bottles  may  be  applied  to  the  feet. 
Strychnine  may  be  given,  and  if  the  pain  is  very  severe, 
morphia  may  be  required.  It  may  be  necessary  to  give 
a  saline  infusion  (cf.  Wounds,  p.  42). 

The  local  treatment  of  a  superficial  injury,  that  is,  of 
the  first,  second  or  third  degree,  is  first  to  render  the 
wound  aseptic.  Blisters  should  be  incised,  and  the  fluid 
squeezed  out.  A  saturated  solution'  of  sodium  bicar- 
bonate often  relieves  the  pain.  Another  method  fre- 
quently used  is  to  dress  the  injury  with  gauze  soaked 
in  a  solution  of  picric  acid  (gr.  v.  ad.  ^i),  or  to  paint 
on  a  mixture  of  castor  oil  one  part  and  collodion  two 
parts.  This  latter  dressing  caiises  much  smarting  pain 
when  applied,  but  soon  affords  relief.  If  there  is  little 
or  no  sepsis,  boracic  acid  ointment  forms  a  good  dress- 
ing. At  the  present  day  the  picric  acid  dressing  is  most 
in  favour. 


WOUNDS  47 

In  burns  of  severer  degree,  great  difficulty  may  be 
experienced  in  removing  dirt  and  pieces  of  clothing. 
&c.,  from  the  wound.  The  patient  should  be  placed  in 
a  warm  boracic  acid  bath  (100°  F.),  and  the  debris 
allowed  to  float  off.  Great  care  must  be  taken  to 
ensure  that  the  temperature  remains  fairly  constant.  If 
this  measure  is  not  successful,  it  may  be  necessary  to 
give  a  general  anaesthetic,  and  scrape  or  cut  away  the 
dirt,  &c.  In  these  conditions,  the  wound  will  be  best 
treated  by  fomentations  until  it  has  been  rendered 
aseptic. 

In  order  to  hasten  healing  and  prevent  fibrous  con- 
traction, when  a  large  area  of  skin  has  been  destroyed, 
skin  grafting  should  be  employed. 

In  very  severe  burns  of  the  limbs,  the  question  of 
amputation  may  have  to  be  considered. 

A  scald  of  the  glottis  requires  special  mention,  as  the 
great  oedema  caused  often  necessitates  -immediate 
tracheotomy  to  save  the  patient's  life.  If  the  sym- 
ptoms are  not  so  urgent,  scarification  of  the  injured 
area  may  be  tried. 

In  young  children,  the  inunction  of  a  large  quantity 
of  mercury  ointment  is  said  by  some  to  have  a  greatly 
beneficial  effect  upon  the  oedema.  Facilities  for  imme- 
diate tracheotomy  should,  however,  be  always  at  hand. 
Mr.  Barker  has  experienced  considerable  success  with 
this  method.  As  much  mercurial  ointment  as  possible 
should  be  used,  but  to  avoid  subsequent  toxic  effects, 
the  skin  must  be  carefully  washed  afterwards. 

Burns  due  to  lightning  or  electricity  require  treat- 
ment on  general  lines,  but  healing  in  these  cases  is  com- 
monly slow. 

Healing  of  Wounds. 

There  are  three  methods  by  which  a  wound  may 
heal :  first  intention,  second  intention,  and  third  inten- 
tion. 

Healing  by  first  intention  occurs  in  incised  wounds, 
in  which  (i)  the  tissues  are  healthy;  (2)  no  sepsis  is 
present;  (3)  the  haemorrhage  is  completely  arrested; 
and  (4)  the  edges  are  placed  in  exact  apposition. 

In  a  few  hours  the  edges  are  held  together  by  a  non- 
vascular, glutinous  material.  After  twenty-four  hours 
this   material   will   have  become   vascularized.      These 


48  SURGERY    FOR    DENTAL     STUDENTS 

newly-formed  blood-vessels,   however,  disappear  later, 
leaving  a  non-vascular  scar. 

When  examined  microscopically  it  will  be  found  that 
the  process  is  simply  a  mild,  aseptic  inflammation,  in- 
volving only  just  the  neighbourhood  of  the  injury.  All 
the  stages  of  inflammation  occur,  hypersemia,  stasis, 
exudation,  and  repair.  By  the  cellular  exudation  and 
the  fibrin,  the  edges  of  the  wound  are  first  glued 
together.  Loops  of  new  blood-vessels  then  form  in 
this  substance,  and  so  the  edges  join. 

The  clinical  signs  of  inflammation  are  also  present 
in  a  very  slight  degree,  i.e.,  redness,  swelling,  heat,  and 
pain.  These  usually  disappear  in  twenty-four  hours. 
As  soon  as  the  edges  have  joined  the  inflammation  sub- 
sides, but  the  formation  of  fibrous  tissue  continues  until 
a  firm,  non-vascular  scar  is  formed. 

Another  variety  of  healing  by  first  intention  is  heal- 
ing under  a  scab.  The  scab  is  formed  by  blood  clot, 
and  acts  simply  as  a  "  dressing,"  protecting  the  wound 
from  sepsis  or  mechanical  irritation. 

Healing  by  second  intention  or  by  granulation 
occurs  when  one  or  more  of  the  factors  necessary  to 
ensure  healing  by  first  intention  is  absent.  Sepsis  may 
have  occurred,  a  foreign  body  may  be  present,  the 
nature  of  the  wound  may  be  such  that  the  edges  could 
not  be  got  into  correct  apposition,  &c. 

In  this  case  the  signs  of  inflammation  occur  as  before., 
but  instead  of  subsiding  within  twent3^-four  hours  they 
tend  to  progress.  The  discharge  increases-in  amount, 
and  soon  suppuration  occurs.  The  granulating  surface 
then  heals,  as  has  been  described  under  Ulceration 
(q.v.). 

Healing  by  third  intention  or  by  union  of  two 
granulating  surfaces  occurs  in  widely  gaping  wounds, 
where  considerable  loss  of  tissue  has  taken  place.  In 
each  of  the  two  surfaces  of  the  wound  granulation 
tissue  is  formed  in  the  manner  described  above.  The 
granulating  surfaces  gradually  approach  one  another 
until  union  occurs. 

Certain  further  complications  which  may  be  present 
in  a  wound  require  mention.  -^  — — -- 

Sepsis  in  a  wound  may  cause  general,  constitfitional 
effects  of  varying  intensity.  Three  conditions  are 
described,    vi^.,    saprcemia,    septiccemia,    and    pysemia. 


WOUNDS  49 

Various  bacteria  may  be  present  in  these  conditions, 
streptococci  and  staphylococci  being  the  most 
common. 

Sapraemia  results  from  absorption  into  the  circulation 
of  toxic  products  produced  by  bacteria,  the  organisms 
themselves  being  present  only  in  the  local  lesion.  The 
clinical  signs  of  the  condition  generally  commence 
about  one  to  three  days  after  infection,  with  a  sharp 
rise  of  temperature  (102°  to  103°  F.),  often  with  a 
rigor.  This  is  associated  with  a  rapid,  weak  pulse,  a 
dry,  furred  tongue,  headache,  loss  of  appetite,  and 
general  weakness.  There  may  be  some  delirium.  As 
a  rule,  constipation  is  present;  but  if  the  toxins  act 
chiefly  upon  the  gastro-intestinal  tract,  severe  diarrhoea 
and  vomiting  may  occur ;  if  this  condition  be  not  rapidly 
treated,  collapse  and  death  may  follow.  When  the 
action  of  the  toxins  involves  chiefly  the  central  nervous 
system,  the  delirium  in  the  early  stages  is  more  marked, 
and  is  followed  by  coma.  Slight  albuminuria  is  often 
present. 

The  treatment  is  to  remove  the  local  cause  of  the 
disease  by  opening  up  and  cleansing  the  wound,  and 
to  assist  in  the  elimination  of  toxic  products  by  pur- 
gation and  diuresis.  Rectal  injection  or  infusion  under 
the  skin  of  normal  saline  solution  is  often  of  great 
service. 

Chronic  Saprsemia,  or  Hectic  Fever,  is  a  similar 
condition,  the  absorption  of  toxins  continuing  for  a 
considerable  time.  The  clinical  signs  are  continued 
pyrexia,  and  great  emaciation  and  weakness.  The 
long  continued  presence  of  toxic  substances  in  the 
blood  tends  to  produce  a  type  of  degeneration  known 
as  albuminoid,  waxy,  lardaeeous,  or  amyloid  degenera- 
tion in  the  liver,  spleen,  and  other  organs. 

The  treatment  is  similar  to  that  of  the  acute  type. 

Septicaemia  differs  from  saprsemia  in  this  particular : 
that  in  septicemia  the  organisms  actually  gain  access 
to  and  multiply  in  the  blood-stream,  by  which  means 
they  are  carried  to  the  various  organs  of  the  body. 

The  clinical  signs  are  similar  to  those  of  saprsemia, 
but  more  marked.  There  is  almost  always  a  definite 
rigor  at  the  commencement,  usually  within  forty-eight 
hours  of  the  primary  infection,  and  the  temperature  is 
higher,  commonly  104°  to  105°  F. 
4 


50  SURGERY     FOR     DENTAL     STUDENTS 

Pyaemia  is  really  a  form  of  septicaemia  in  which,  in 
addition  to  the  other  phenomena  mentioned  above, 
secondary  abscesses  are  formed  in  various  parts  of  the 
body.  These  pyaemic  abscesses  are  most  common  in 
the  lungs,  spleen,  liver,  kidneys,  and  brain,  but  they 
may  occur  in  any  part  of  the  body.  Venous  thrombosis 
occurs  in  the  neighbourhood  of  the  local  lesion.  From 
the  thrombus  infective  emboli  become  detached,  and, 
passing  round  in  the  blood-stream,  lodge  in  some  small 
vessel;  at  the  points  where  they  lodge,  pyaemic" 
abscesses  may  be  formed. 

The  clinical  signs  of  pyaemia  much  resemble  those  of 
septicaemia.  It  does  not  usually  begin  for  a  week  after 
primary  infection.  It  is  ushered  in  with  a  rigor,  and 
throughout  the  course  of  the  disease  rigors  occur  at 
intervals  (there  is  rarely  more  than  the  rigor  at  the 
onset  in  septicaemia).  The  temperature  remains  hig-h, 
the  pulse  rapid  and  weak;  persistent  vomiting  and 
diarrhoea  occur,  both  the  vomit  and  the  stools  being 
frequently  bloodstained.  Slight  jaundice,  albuminuria 
and  haematuria  may  be  present. 

Treatment  as  before  is  directed  first  to  the  local 
lesion.  All  secondary  abscesses  that  can  be  reached 
must  be  opened  and  cleansed. 


CHAPTER   VII. 
HEMORRHAGE. 

Haemorrhage  is  the  escape  of  blood  from  the  vessels. 
When  the  blood  escapes  into  any  cavity  in  the  body 
(such  as  the  uterus,  &c.),  or  into  the  tissues,  the 
haemorrhage  is  internal;  when  the  blood  escapes  from 
the  surface  of  the  body,  the  haemorrhage  is  external. 

The  bleeding  differs  according  to  the  vessel  from 
which  it  occurs.  In  arterial  hceniorrhage,  the  blood  is 
bright  red  in  colour;  it  escapes  from  the  proximal  end 
of  the  vessel  in  jets,  practically  synchronous  with  the 
cardiac  systole.  In  venous  hcemorrJiage  the  blood  is 
dark  purple  in  colour;  it  does  not  escape  in  jets,  but 
flows  continuously.  Capillary  hceniorrhage  occurs  as 
a  continuous,  slight  oozing  of  blood  from  the  wounded 
surface. 

The  bleeding  which  occurs  at  the  moment  of  injury 
is  known  as  Primary  haemorrhage.  The  recurrence  of 
bleeding  within  twenty-four  hours  of  the  arrest  of 
the  primary  haemorrhage  is  termed  Recurrent,  Re- 
actionary, or  Intermediate  haemorrhage.  Secondary 
haemorrhage  is  any  recurrence  of  bleeding  more  than 
twenty-four  hours  after  the  primary  haemorrhage  has 
been  arrested. 

The  treatment  of  primary  arterial  haemorrhage  has 
already  been  discussed  under  wounds  (Chapter  VI). 
Venous  haemorrhage  will  in  the  majority  of  cases  yield 
to  the  presence  of  a  dressing.  If  a  large  vein  has 
been  injured,  it  may  be  necessary  to  dissect  out  the 
two  ends  and  apply  ligatures. 

Capillary  haemorrhage  is  best  treated  by  the  appli- 
cation of  pressure:  hot  water  (iio°  F.)  is  often  useful. 
If  the  position  of  the  wound  is  such  that  pressure  can- 
not readily  be  applied,  recourse  must  be  had  to  styptics 
{sec  Chapter  VI). 

Recurrent  or  Reactionary  Hsemorrhage  may  be 
due  to  the  breaking  down  of  the  clots  formed  in  the 
injured   vessels,    by   increased   blood-pressure;   to   the 


52  SURGERY    FOR    DENTAL     STUDENTS 

slipping  of  a  ligature;  or  to  the  perforation  of  a 
damaged  vessel.  If  slight,  it  may  be  arrested  by- 
elevation  of  the  part,  and  form  pressure  on  the  wound. 
If  this  fails,  the  wound  must  be  explored,  and  the 
bleeding  vessel  sought  and  tied.  When  the  vessel 
cannot  be  sufficiently  isolated  to  admit  of  the  applica- 
tion of  a  ligature,  the  actual  cautery  may  be  used. 

Secondary  Haemorrhage  is  frequently  the  result 
of  sepsis.  The  micro-organisms  may  gain  access  either 
through  the  external  wound  or  via  the  blood-stream. 
In  either  case,  if  the  clot  in  the  vessel  becomes  infected, 
it  softens  and  is  consequently  no  longer  sufficient  to 
withstand  the  pressure  of  the  blood.  Ansemic  patients 
are  very  liable  to  suffer  from  tiresome  secondary 
hsemorrhagre.  This  is  often  the  case  after  the  extrac- 
tion of  teeth. 

The  principles  of  treatment  are  the  same  as  above 
described,  vi^.,  in  slight  cases,  elevation  of  the  part 
and  firm  pressure;  if  necessary,  operative  interference, 
and  ligature  of  the  vessel.  In  very  septic  cases,  where 
vessel  is  too  much  diseased  to  hold  a  ligature,  the  main 
artery  must  be  exposed  through  a  fresh  incision  above 
the  injury,  and  a  ligature  applied  to  it  there.  In  very 
severe  cases,  amputation  may  have  to  be  considered. 

Three  conditions  which  resemble  one  another  in 
their  clinical  manifestations  may  present  themselves, 
vi^.,  Shock,  Collapse  and  Syncope. 

Shock  is  a  condition  of  lowering  of  vitality,  follow- 
ing injury  or  emotional  disturbance.  It  is  commonly 
supposed  to  be  due  to  a  disturbance  of  the  vasomotor 
centre  in  the  medulla.  It  varies  in  degree  according 
to  the  severity  of  the  injury,  the  susceptibility  of  the 
patient  (a  so-called  ''  nervous  "  patient  being  particu- 
larly liable,  while  children  are  more  susceptible  than 
adults  as  a  rule),  and  the  part  injured  (injury  to  the 
viscera  is  more  likely  to  produce  severe  shock  than 
injury  to  a  limb).  The  extent  of  the  injury  also  affects 
the  severity  of  the  shock,  e.g.,  a  deep  burn  which  is 
limited  in  extent  is  not  so  likely  to  cause  severe  shock 
as  a  burn  which,  though  not  penetrating  deeply, 
involves  a  large  area  of  surface. 

Intense  pain  is  a  factor  which  tends  to  increase  the 
severity  of  shock. 

The  onset  is  sudden.     The  patient  is  in  a  conditioni 


HyEMORRHAGE  53 

of  extreme  weakness,  and  mental  apathy.  In  the 
earher  stages,  he  can  generally  be  roused,  and  per- 
suaded to  answer  questions,  but  later  may  become 
insensible.  The  face  is  blanched,  the  respirations 
shallow  and  irregular,  the  temperature  subnormal,  the 
pulse  weak,  irregular  and  rapid. 

The  first  sign  of  recovery  is  usually  an  attack  of 
vomiting.  All  the  signs  then  begin  to  abate;  the 
colour  returns,  the  pulse  becomes  stronger  and  slower, 
the  temperature  rises,  often  above  normal,  and  the 
mental  apathy  slowly  disappears. 

Collapse  differs  from  shock  in  that  its  onset  is 
not  sudden  but  gradual.  It  depends  upon  the  with- 
drawal of  large  quantities  of  fluid  from  the  body  by 
haemorrhage,  severe  diarrhoea,  vomiting,  &c.  The 
symptoms  and  signs  are  similar  to  those  described 
under  shock,  and  it  should  be  treated  upon  similar 
lines.     {See  below.) 

Syncope  or  Fainting  results  from  sudden  cerebral 
anaemia,  due  to  temporary  stoppage  of  the  heart.  It 
usually  depends  upon  similar  conditions  to  those  des- 
cribed as  responsible  for  shock,  viz.,  severe  injury, 
pain,  or  emotional  disturbance.  The  signs  are  similar, 
but  are  all  compressed  into  quite  a  short  space  of  time. 

Treatment. — The  first  thing  to  do  is  to  place  the 
head  lower  than  the  heart  to  assist  the  flow  of  blood 
to  the  brain.  Then  loosen  any  tight  clothing  especially 
round  the  neck.  In  order  to  stimulate  the  heart 
ammonia  may  be  held  under  the  nose,  or  spiritus 
ammoniae  aromaticus  (5i  ad.  ^ss  of  water)  may  be 
given  by  the  mouth  if  the  patient  can  swallow.  Ice- 
cold  water  may  be  thrown  in  the  face.  In  cases  of 
collapse,  a  saline  infusion  may  be  of  great  value;  an 
ounce  of  brandy  may  be  added  to  the  saline  infusion. 
A  hypodermic  injection  of  strychnine  (liq.  strych. 
hydrochlor.  niiv),  or  of  ether  iixv,  may  be  given. 

If  these  remedies  fail,  and  the  facilities  for  operation 
are  at  hand,  actual  massage  of  the  heart  through  an 
incision  below  the  costal  margin  may  be  resorted  to. 

There  are  certain  terms  used  in  connection  with 
haemorrhage  from  certain  situations,  the  meaning  of 
which  must  be  explained. 

Epistaxis,  bleeding  from  the  nose  (see  Chapter 
XXIV). 


54  SURGERY    FOR    DENTAL     STUDENTS 

Hcsmoptysis,  bleeding  from  the  lungs  or  air  pas- 
sages. 

Hccmatcmesis,  bleeding  from  the  stomach. 

Hcematuria,  blood  in  the  urine. 

Melcena,  the  presence  of  altered  blood  in  the 
motions,  the  stools  being  black  and  tarry.  Bright  red 
blood  in  the  motions  is  not  melsena.  Information  with 
regard  to  the  last  four  of  these  conditions  should  be 
sought  in  text-books  on  medicine. 


CHAPTER    VIII. 
DISEASES    OF   ARTERIES    AND    VEINS. 

Inflammation  of  an  artery  is  called  Arteritis.  It 
may  commence  from  within  the  artery,  and  involve  the 
tunica  intima  {Endarteritis),  or  it  may  come  from  the 
tissue  around  the  vessel  {Periarteritis). 

Arteritis  may  be  either  acute  or  chronic. 

Acute  Arteritis  is  divided  according  to  its  cause  into 
non-infective  and  infective. 

The  non-infective  variety  is  a  simple  inflammatory 
process  by  which  a  vessel  is  closed  up  after  injury, 
ligature,  or  lodgment  of  an  embolus. 

The  infective  form  usually  follows  a  septic  wound  or 
septic  embolus.  Signs  of  acute  suppurative  inflam- 
mation appear  in  the  vessel.  It  is  the  most  common 
cause  of  secondary  haemorrhage  {q.v.,  p.  51).  In 
dental  operations  this  cause  does  not  weigh  so  heavily 
as  it  does  in  major  operations.  Aneurism  may  follow 
{q.v.). 

Chronic  Arteritis  may  depend  upon  a  variety  of 
causes,  of  which  the  most  important  are: — Continued 
high  blood-pressure  due  to  renal  disease,  &c.;  the 
action  of  certain  poisons,  notably  lead;  some  general 
diseases,  such  as  syphilis  (perhaps  the  most  frequent), 
diabetes,  tuberculosis  (rarely).  In  old  people  a 
calcareous  degeneration  of  the  vessels  may  occur.  The 
changes  which  are  associated  with  the  condition  differ 
somewhat,  according  to  the  size  of  the  vessel. 

In  the  larger  arteries  a  proliferation  of  the  intima  in 
patches,  with  a  great  tendency  to  fatty,  fibroid,  or 
calcareous  degeneration,  occurs;  the  media  and  adven- 
titia  are  later  affected.  The  later  stages  of  the  con- 
dition are  known  as  Atheroma,  and  are  characterized  V 
by  extensiA-e  degeneration  in  the  walls.  Aneurism 
may  result. 

In  syphilitic  endarteritis ,  the  smaller  arteries  are 
chiefly  affected.  There  is  considerable  proliferation  of 
the  intima;  this  proliferation  is  usually  not  in  patches, 
but  involves  the  whole  circumference  of  the  vessel. 


/ 


56  SURGERY    FOR    DENTAL     STUDENTS 

The  media  is  thickened  to  a  sHght  extent;  the 
adventitia  rather  more.  Fatty  degeneration  is  not  so 
common.  The  condition  may  progress  to  complete 
obhteration  of  the  lumen  of  the  vessel. 

Tuberculous  arteritis  is  a  similar,  but  much  rarer, 
condition. 

Treatment  should  be  directed  towards  the  underlying 
cause.     All  unnecessary  strain  must  be  avoided. 

An  Aneurism  is  a  dilatation  of  a  vessel  wall,  forming 
a  sac  filled  with  blood.  It  commonly  follows  syphilitic 
or  other  arteritis;  severe  strains  may  result  in  aneur- 
ism, but  in  these  cases  there  is  probably  always  some 
diseased  condition  of  the  wall  previously  present. 

Three  types  of  aneurism  are  described,  vis. : — 

(1)  Fusiform— The  whole  circumference  of  the  ves- 
sel is  dilated;  it  commonly  follows  extensive  arterial 
disease. 

(2)  Sacculated. —  A  large  sac  with  a  small  opening 
communicating  with  the  artery  is  formed,  by  the  dila- 
tation of  a  weak  patch  in  the  wall. 

(3)  Dissecting. —  The  blood  passes  between  the 
coats  of  the  vessel,  either  between  media  and  adven- 
titia, or  in  the  substance  of  the  media,  forming  a  sac 
actually  within  the  wall  of  the  vessel. 

The  large  arteries  of  the  thorax  are  the  most  com- 
mon situations  for  aneurism. 

The  clinical  signs  are:  (i)  The  presence  of  a  turnout 
which  pulsates.  This  pulsation  is  synchronous  with 
the  heart's  apex  beat  and  is  expansile  in  charac- 
ter. Pressure  upon  the  main  artery  on  the  proximal 
side  causes  the  pulsations  to  cease,  and  the  tumour 
becomes  smaller,  filling  up  again,  as  soon  as  the  artery 
is  released. 

(2)  A  systolic  and  sometimes  also  a  diastolic  murmur 
is  heard  over  the  tumour. 

(3)  A  systolic  thrill  may  be  felt. 

(4)  Signs  dependent  upon  the  pressure  exerted  by 
the  tumour,  e.g.,  enlarged  veins,  pain  or  paralysis  from 
pressure  on  nerves,  erosion  of  bone  or  soft  tissues,  &c. 

Diagnosis.  —  This  depends  chiefly  upon  the  expansile 
pulsation.  In  tumours  which  exhibit  pulsation  trans- 
mitted to  them  by  an  underlying  vessel,  the  pulsation 
is  not  expansile.  The  pulsation  in  some  sarcomata 
may  be  expansile,  but  these  tumours  are  rarely  found 


DISEASES     OF    ARTERIES     AND     VEINS  57 

in  the  line  of  a  large  artery.  Also,  pressure  upon  the 
main  artery  above  the  tumour,  though  it  stops  the 
pulsation,  does  not  affect  the  size  of  the  tumour.  Con- 
siderable pain  may  result  from  an  aneurism,  without 
verv  obvious  signs;  it  may  then  be  mistaken  for 
neuralgic  pain  such  as  sciatica.  A  careful  physical 
examination  will  generally  reveal  the  true  condition. 

Spontaneous  cure  is  rare.  Rupture  either  externally 
or  internally  may  occur,  often  with  sudden  death. 

Treatment. —  Rest  and  avoidance  of  all  strain  is 
essential.  Antisyphilitic  remedies  (mercury  and 
iodides)  are  of  extreme  importance,  in  all  cases,  even 
where  no  history  of  syphilis  can  be  obtained. 

\'arious  surgical  measures  have  been  devised.  If  a 
small  vessel  is  involved,  ligatures  may  be  applied  above 
and  below  the  sac,  and  the  whole  removed. 

Where  this  is  impossible,  ligatures  may  be  applied 
without  excision  of  the  sac.  These  procedures  are 
not  without  danger,  owing  to  the  risk  of  secondary 
haemorrhage  from  the  diseased  vessel. 

Another  method  is  to  place  a  large  quantity  of  gold 
wire  in  the  sac,  and  pass  an  electric  current  through, 
for  the  purpose  of  inducing  clotting.  Usually  only 
temporary  benefit  is  obtained,  though  quite  recent 
results  have  been  more  encouraging.  Macewen's 
method  of  acu-puncture,  that  is,  sticking  a  number  of 
needles  into  the  sac  and  leaving*  them  there,  to  induce 
clotting,  is  rarely  performed.  In  the  limbs  amputation 
may  have  to  be  performed. 

A  so-called  Ditfuse  Traumatic  Aneurism  is  not  an 
aneurism  in  the  strict  sense  of  the  word,  because  the 
sac  into  which  the  blood  escapes  is  not  composed  of 
the  coats  of  the  vessel,  but  of  the  surrounding  soft 
tissues.  It  follows  stabbing  injuries;  suppuration  and 
rupture  may  result. 

freatment  is  to  ligature  both  ends  of  the  injured 
vessel,  and  remove  the  sac. 

An  Arterio-Yenous  Aneurism  is  an  abnormal  con- 
nection between  an  artery  and  a  vein.  They  are 
mostly  traumatic  in  origin.     Two  kinds  occur:  — 

An  aneurismal  varix  is  a  direct  connection  between 
artery  and  vein,  no  sac  intervening. 

When  the  two  vessels  are  connected  by  a  dilated  sac, 
the    condition    is    called    a    varicose    aneurism.     The 


58  SURGERY    FOR    DENTAL     STUDEI^'IS 

venous  walls  are  much  dilated  by  the  pressure  of  the 
arterial  impulse,  and  are  very  liable  to  rupture. 

The  physical  signs  are  those  of  a  small  aneurism. 

Treatment  is  to  ligature  the  artery  above  and  below, 
and  if  this  fails,  the  vein  also. 

I nflanimation  of  a  "uein  is  known  as  Phlebitis.  Like 
Arteritis  it  may  be  non-infective  or  infective. 

Simple  Non-infective  Phlebitis  may  follow  injury. 
It  also  occurs  in  conjunction  with  Thrombosis.  Other 
cases  are  called  idiopathic,  which  is  a  convenient  way 
of  disguising  our  ignorance  as  to  the  cause  of  the 
condition.  Phlebitis  is  a  not  infrequent  sequel  of 
Influenza. 

Infectiye  Phlebitis  may  follow  actual  injury  to  the 
vessel,  or  may  spread  from  an  adjacent  septic  wound. 
It  may  also  result  from  the  presence  of  micro-organ- 
isms in  the  blood. 

The  ordinary  signs  of  inflammation  are  found  in  the 
vein.  In  the  septic  variety,  suppuration  and  softening 
of  any  clot  formed  may  occur,  resulting  in  the  forma- 
tion of  an  abscess. 

Thrombosis  (clotting)  is  a  common  accompani- 
ment of  phlebitis.  The  clot  may  become  organized, 
and  the  vessel  be  altogether  obliterated,  or  a  canal 
may  gradually  be  formed,  and  the  flow  of  blood 
recommence.  Embolisms  may  be  thrown  off  from  the 
thrombus,  and  lodge  in  distant  parts  of  the  body.  In 
the  infective  variety,  this  is  perhaps  the  chief  danger 
to  be  feared. 

Phlegmasia  Alba  Dolens  or  ''white  leg''  is  a  con- 
dition of  thrombosis  spreading  from  the  uterine  sinuses 
to  the  veins  of  the  lower  extremity  in  pregnancy  or 
after  delivery. 

Clinical  Signs. — If  the  vein  be  superficial,  it  may  be 
felt  as  a  hard,  painful,  *' nubbly"  swelling,  the  skin 
covering  it  has  a  dark  bluish  appearance,  due  to  the 
enlargement  of  the  underlying  vein.  Slight  oedema  of 
the  area  normally  drained  by  the  affected  vessel  may 
be  present,  but  the  venous  circulation  is  so  free  that 
this  is  not  as  a  rule  a  marked  feature,  unless  a  large 
vein  is  affected.  When  suppuration  occurs,  the  swell- 
ing does  not  feel  so  hard. 

When  a  deeper  vein  is  affected,  deep  seated  pain, 
tenderness  along  the  line   of  the  vessel,   some  fever. 


DISEASES     OF    ARTERIES    AND    VEINS  59 

oedema,  and  whiteness  of  the  skin  must  be  reHed  upon 
in  diagnosis. 

Later,  Pyaemia  may  supervene  (q.v.). 

Treatment. — In  the  non-infective  type,  absolute  rest 
and  immobiHzation  of  the  part  until  all  signs  of 
inflammation  have  disappeared,  is  essential.  The  part 
may  be  painted  with  glycerine  of  belladonna  and 
fomented.  The  dressing  should  be  so  arranged  that  it 
can  be  changed  without  moving  the  part. 

In  infective  phlebitis,  in  addition  to  the  above  treat- 
ment, if  abscesses  are  present  they  should  be  opened. 
Where  possible,  a  lig'ature  placed  on  the  proximal  side 
of  the  diseased  area  may  prevent  the  spread  of  infec- 
tion. There  is  some  danger  in  this  procedure,  as  the 
slight  injury  to  the  already  diseased  vessel  wall 
involved  in  the  pressure  of  the  ligature  may  be  suffi- 
cient to  determine  thrombosis  above  it.  In  severe 
cases  involving  the  limbs,  amputation  may  have  to  be 
considered. 

Yaricose  Yeins  is  a  condition  in  which  the  affected 
vessels  are  dilated,  lengthened,  tortuous,  and  often 
thrombosed.  The  veins  of  the  leg  are  most  commonly 
affected.  The  causes  of  the  condition  are  some 
inherent  weakness  of  the  wall  or  valves  of  the  vessel, 
combined  with  unusual  strain,  such  as  long  continued 
standing  or  severe  exertion.  The  pressure  of  large 
abdominal  or  pelvic  tumours  offers  increased  resistance 
to  the  return  of  blood  to  the  heart,  and  so  may  cause 
varicosity.  In  a  similar  way,  cardiac  and  hepatic 
diseases,  by  interference  with  the  flow  of  blood,  may 
be  responsible  for  the  condition. 

Clinical  Signs. — The  tortuous  varicose  veins  are 
most  commonly  superficial,  and  may  be  seen  and  felt. 
They  are  usually  painful.  An  impulse  and  a  thrill 
may  be  felt  on  coughing. 

Piles  are  due  to  a  varicose  condition  of  the  veins  of 
the  rectum. 

A  Varicocele  is  a  similar  condition  affecting  the 
spermatic  veins. 

Treatment.— Mechanical  support  by  means  of  an 
elastic  bandage  is  often  sufficient  to  allay  symptoms. 
Operative  interference  may  be  required.  Tlie  veins 
may  be  divided  between  two  ligatures,  or  a  piece  of 
the  vein  on  the  cardiac  side  excised. 


y 


6o  SURGERY    FOR    DENTAL     STUDENTS 

Sepsis  requires  treatment  on  general  lines.  If  a 
varicose  vein  ruptures,  the  limb  should  be  elevated  and 
firm  pressure  applied  to  arrest  haemorrhage. 

Piles  should  be  seized  with  forceps,  ligatured,  and 
removed  with  scissors,  or  the  actual  cautery.  A  more 
certain  cure  can  be  obtained  by  removal  of  the  "  pile 
bearing  area,"  that  is,  the  lower  part  of  the  rectal 
mucous  membrane  (Whitehead's  operation).  It 
should  be  borne  in  mind  that  piles  are  very  often 
manifestations  of  cardiac  or  other  general  diseases. 

YaricoceJes  do  not  as  a  rule  require  any  treatment. 
If  they  cause  pain  ligatures  should  be  applied,  and  as 
much  as  possible  of  the  affected  vein  excised. 

Tumours  of  Vessels  (see  Chapter  XIV). 


CHAPTER    IX. 
INJURIES  AND   DISEASES  OF  NERVES. 

Injuries." — A  blow  upon  a  nerve,  especially  where 
it  is  close  to  a  bone,  may  cause  severe  pain  and  a 
sensation  of  "  pins  and  needles."  There  may  be  slight 
temporary  paresis  of  muscles.  These  symptoms 
usually  disappear  rapidly  without  treatment.  In  per- 
sons who  are  "  out  of  sorts  "  or  by  nature  hysterical, 
the  symptoms  are  proportionately  more  severe.  Con- 
tinued pressure,  such  as  may  be  caused  to  the  brachial 
plexus  by  hanging  the  arm  over  a  chair,  may  result  in 
inflammation  of  the  nerve  (see  Neuritis). 

Compression  of  a  nerve  from  a  tumour,  involve- 
ment in  callus  after  a  fracture,  or  in  the  scar  tissue 
following  a  wound,  results  in  progressive  pain  and 
muscular  weakness  in  the  area  supplied  by  the  nerve. 

Treatment  is  to  remove  the  cause,  by  operation  if 
necessary. 

Partial  or  complete  division  of  a  nerve  may  occur; 
the  nerve  may  either  be  torn  or  cut  across.  It  is  rare 
for  an  injury  caused  by  tearing  to  result  in  complete 
division.  If  the  severance  is  complete  the  distal  por- 
tions of  the  axis-cylinders  degenerate.  From  the 
proximal  portions,  new  processes  grow  out.  If  no 
septic  infection  occurs,  and  the  cut  ends  of  the  nerve 
are  in  apposition,  regeneration  of  the  nerve  commonly 
takes  place,  but  the  process  is  slow.  The  signs  of 
complete  division  of  a  mixed  nerve  are  anaesthesia  over 
the  corresponding  area  of  skin,  paralysis  and  wasting 
of  the  muscles  supplied,  and  trophic  lesions  of  the  skin, 
sometimes  terminating  in  dry  gangrene. 

Treatment. — If  the  nerve  is  a  small  one,  no  treatment 
is  required.  In  the  case  of  a  large  nerve  the  cut  ends 
should  be  immediately  sutured  together  with  aseptic 
precautions.  More  elaborate  operations  such  as  nerve- 
grafting  (that  is,  inserting  a  piece  of  healthy  nerve 
between  the  divided  ends  of  the  injured  one,  and  sutur- 


6j  surgery   for   dental   students 

ing'  at  both  points)  or  nerve  anastojnosis  (suturing  the 
distil  end  of  the  injured  nerve  to  the  proximal  end  of 
some  other  similar  healthy  nerve)  have  been  employed. 
After  any  of  these  operative  procedures,  a  course  of 
massage  and  electrical  treatment  will  be  required. 

Diseases  of  Nerves. 

Inflammation  of  a  nerve  is  called  Neuritis.  It  may 
be  acute  or  chronic. 

Acute  neuritis  may  follow  injury,  septic  infection 
from  a  wound,  and  cert^ain  general  conditions,  notably 
gout,  rheumatism,  and  alcoholism. 

The  symptoms  are  severe  pain  along  the  line  of  the 
nerve,  and  over  the  cutaneous  area  it  supplies,  with 
some  muscular  weakness. 

Treatment  should  include  rest  of  the  part  involved. 
Glycerine  of  belladonna  fomentations  may  be  applied 
to  relieve  the  pain.  A  proprietary  article  sold  under 
the  name  of  Antiphlogistine  applied  hot  as  a  plaster  is 
often  of  great  use.  Electrical  treatment  ,and  massage 
may  be  required.     Bromides  may  be  useful. 

Chronic  neuritis  may  result  from  injury  or  com- 
pression, from  syphilis,  gout,  rheumatism,  or  diabetes; 
from  the  action  of  certain  poisons,  notably  lead, 
arsenic,  and  alcohol,  and  following  certain  acute 
specific  fevers,  e.g.,  diphtheria,  influenza,  &c.  There 
are  certain  tropical  complaints,  of  which  neuritis  is  a 
feature,  but  these  are  outside  the  scope  of  the  present 
work. 

The  Symptoms  are  much  the  same  as  in  the  acute 
variety :  Tingling  sensations  and  pain,  anaesthesia 
(sometimes  preceded  by  hyperaesthesia)  and  paresis  or 
paralysis  of  muscles. 

Treatment. — The  underlying  cause  will  require  to  be 
dealt  with.  The  part  must  be  kept  absolutely  at  rest, 
and  massage,  electrical  treatment,'^  ionization, &c.,  may 
be  tried.  Recovery  is  often  very  slow.  In  certain  purely 
sensory  nerves,  it  may  be  possible  to  excise  a  piece  of 
the  nerve  completely,  above  the  lesion,  and  so  relieve 
the  pain  by  interrupting  the  path  of  sensory  impulses. 

*  An  electrical  method  of  treatment  by  which  certain  ions  are  intro- 
duced localh-  into  the  affected  tissues. 


INJURIES     AND     DISEASES     OF     NERVES  63 

Anodynes  such  as  aspirin  and  phenacetin  may  be  given^ 
or  in  very  severe  cases    morphia  may  be  required. 

Tumours  of  Nerves  (see  Chapter  XIV). 

Diseases  of  Individual  Nerves. — The  local  mani- 
festations of  neuritis  vary,  of  course,  according  to  the 
particular  nerve  or  nerves  affected  by  the  disease. 
Space  compels  us  to  confine  our  attention  to  a  few  of 
the  more  miportant  nerves,  and  phenomena  included 
within  their  sphere  of  influence. 

The  anatomical  course  of  the  nerve,  and  its  muscular 
and  sensory  distribution,  combined  with  knowledge  of 
the  general  features  of  neuritis  as  set  forth  above, 
should  enable  the  student  to  form  a  pretty  clear  idea 
of  the  phenomena  likely  to  present  themselves  in  any 
given  case.  Certain  nerves,  notably  the  fifth  and 
seventh  cranial,  are  of  special  importance  in  dental 
practice,  and  must  be  dealt  with  in  some  detail. 

The  Trigeminal  or  Fifth  Cranial  Nerve  may  be 
the  site  of  severe  neuritis,  remarkable  for  the  intensity 
and  paroxysmal  character  of  the  pain  caused,  and 
known  as  Tic  Douloureux  or  Epileptiform  Tic.  It  is 
commonly  due  in  the  first  place  to  irritation  of  the  \| 
nerve  supplying-  a  tooth.  The  disease  begins  as  a  ' 
rule  in  a  single  branch,  often  the  inferior  dental,  infra- 
orbital or  supraorbital.  Thence  it  may  spread,  some- 
times rapidly,  sometimes  slowly  to  involve  part  or 
more  rarely  the  whole  of  the  remainder  of  the  nerve. 
In  most  cases,  one  division,  at  least,  escapes  altogether. 

The  pain  is  typically  paroxysmal  in  character;  the 
onset  is  sudden,  each  paroxysm  lasting  from  a  few 
seconds  to  two  or  three  minutes,  the  pain  being  of 
extreme  severity.  The  tendency  of  the  disease  to 
begin  in  a  single  branch,  and  spread  to  others  is  repro- 
duced in  the  individual  paroxysms.  The  pain  is  usually 
accompanied  by  increase  of  secretions,  such  as  sweat- 
ing, lachrymation,  and  increase  of  nasal  secretion,  all 
of  which  are  limited  to  the  affected  side. 

Anaesthesia  over  the  cutaneous  area  supplied  may 
be  present,  but  is  not  a  constant  feature. 

Weakness  and  wasting  of  the  muscles  is  generally 
slight,  and  therefore  immaterial;  unilateral  ptosis  (see 
Chapter  XXIX)  may  occur.  Herpes  (sec  below)  may 
be  present. 

Certain  tender  spots,  at  points  where  affected 
branches  pass  through  bony  notches  or  foramina,  may 


64  SURGERY    FOR    DENTAL     STUDENTS 

be  discovered,  the  most  common  poinits  being  at  the 
supraorbital  notch,  and  the  malar  foramen.  It  should 
be  noted  that  these  are  points  where  the  anatomical 
conditions  prohibit  the  expansion  of  the  nerve,  and 
consequently   pain   results. 

Treatment. — In  the  early  stages,  treatment  on  the 
lines  suggested  above  should  be  pursued.  In  severe 
cases,  however,  the  pain  is  of  so  agonising  a  character 
that  extreme  measures  are  rendered  necessary.  Drugs 
are  not,  as  a  rule,  sufficient  in  themselves,  though  in 
some  cases  great  benefit  has  been  obtained  by  the 
use  of  full  doses  of  t!nct.  gelsemii  (xv  minims  three 
times  a  day),  care  being  taken  to  avoid  the  onset  of 
toxic  symptoms  due  to  the  drug. 

The  use  of  ammonium  chloride  in  doses  of  5  gr. 
every  fifteen  minutes  for  an  hour  often  has  consider- 
able effect  upon  the  pain.  Morphia  may  also  be  re- 
quired. 

The  benefit  obtained  by  any  of  these  methods  is 
rarely  more  than  transitory,  and  in  severe  cases  opera- 
tive interference  is  generally  required.  Tlfe  injection 
of  alcohol  into  the  nerve  sheath  may  give  great  relief 
for  a  time,  but  the  pain  commonly  recurs.  The  only 
operative  measure  which  gives  any  real  hope  of  lasting 
cure  is  the  removal  of  the  Gasserian  ganglion.  There 
are  certain  disadvantages  connected  with  its  perform- 
ance, viz.,  the  operation  is  a  difficult  one  to  perform, 
the  shock  is  often  considerable,  and  trophic  lesions  in 
the  eye  on  the  diseased  side  are  apt  to  result  if  great 
care  is  not  taken.  It  is  usual  nowadays  to  stitch  the 
upper  lid  to  the  lower  before  commencing  the  opera- 
tion. Rose  has  successfully  removed  the  lower  half 
of  the  ganglion,  in  cases  where  the  ophthalmic  division 
is  unaffected,  in  order  to  avoid  the  danger  of  these 
trophic   eye   lesions. 

The  Seventh  Cranial  Nerve  is  commonly  affected  by 
disease,  resulting  in  the  condition  known  as  facial 
palsy.  This  may  arise  from  a  variety  of  causes,  of 
which  the  most  frequent  are  :  exposure  to  a  draught, 
the  resulting  condition  being  often  called  rheumatic 
neuritis,  and  iniddlc-car  disease.  Other  less  frequent 
causes  are  fracture  of  the  skull,  the  pressure  of 
tumours,  or  of  intracranial  haemorrhage,  disease  of  the 
temporal  bone,  and  certain  diseases  of  the  central 
nervous  system,  such  as  tabes  or  disseminate  sclerosis. 


INJURIES     AND     DISEASES     OF     NERVES  O5 

Alcoholic  facial  neuritis  is  rare.  Another  cause  is 
injury,  especially  to  the  facial  nerve  of  a  child  when 
delivered  by  forceps.  The  nerve  may  be  attacked  in 
any  part  of  its  course,  the  clinical  pnenomena  varying" 
according  to  the  position  of  the  lesion. 

The  nerve  consists  of  an  upper  and  a  lower  motor 
neuron.  The  latter  includes  the  whole  course  of  the 
nerve  from  the  facial  nucleus  in  the  pons,  to  the  final 
branches  of  supply  to  the  facial  muscles;  while  the 
part  of  the  nerve  above  the  facial  nucleus  is  known 
as  the  upper  motor  neuron.  When  the  upper  motor 
neuron  is  affected,  the  muscular  paralysis  is  commonly 
limited  to  the  lower  part  of  the  face,  on  the  opposite 
side  to  the  lesion.  Emotional  movements  are  affected 
to  a  less  extent  than  voluntary  movements.  There 
is  no  muscular  wasting,  nor  are  the  electrical  reactions 
of  the  muscles  affected.  The  tongue  is  often  involved 
as  well.  Weakness  of  the  limbs  on  the  same  side  as 
the  facial  palsy  may  also  be  present.  The  most 
common  causes  of  this  type  of  facial  palsy  are  intra- 
cranial haemorrhage  or  neoplasm. 

The  clinical  signs  of  a  lower  inotor  neuron  lesion 
of  the  facial  nerve  shew  several  important  differences 
from  the  condition  described  above.  The  paralysis  is 
on  the  same  side  as  the  lesion,  involves  the  upper  and 
lower  halves  of  the  face  equally,  and  affects  emotional 
just  as  much  as  voluntary  movements.  The  facial 
muscles  shew  wasting  and  reaction  of  degeneration. 
If  the  limbs  are  affected,  the  weakness  is  on  the 
opposite  side  to  the  facial  palsy. 

From  these  points,  it  may  be  determined  whether 
the  lesion  is  involving  the  upper  or  lower  motor 
neuron.  The  lower  motor  neuron,  however,  has  a 
long  and  complicated  course,  and  it  is  important  to 
be  able  to  decide  in  what  part  of  this  course  the  lesion 
may  be. 

If  the  nerve  be  affected  before  it  has  left  the  pons, 
in  addition  to  the  ordinary  features  of  a  lower  motor 
neuron  lesion,  other  cranial  nerves  are  commonly 
affected,  notably  the  sixth  nerve,  paralysis  of  the 
external  rectus  muscle  of  the  eye,  followed  by  an 
internal  squint,  resulting.  Taste  and  hearing  are  not 
affected. 

When  the  position  of  the  lesion  is  between  the  point 
5 


J 


66  SURGERY    FOR    DENTAL     STUDENTS 

where  the  nerve  leaves  the  pons,  and  the  geniculate 
ganglion,  hearing  is  commonly  affected  owing  to  in- 
volvement of  the  eighth  nerve.  Taste  is  unaffected, 
and  other  cranial  nerves  are  unlikely  to  be  involved. 

When  the  lesion  is  in  the  Fallopian  canal,  the  sense 
of  taste  is  lost  over  the  anterior  two-thirds  of  the 
tongue,  owing  to  involvement  of  the  chorda  tympani. 
The  auditory  nerve  is  not,  as  a  rule,  affected.  If  the 
lesion  be  above  the  point  where  the  branch  to  the 
stapedius  is  given  off,  this  muscle  will  be  paralysed, 
and  in  consequence  of  this,  low  notes  will  be  heard 
better  than  usual,  owing"  to  over-action  of  the  now 
unopposed  tensor  tympani.  This  is  a  physical  sign, 
the  presence  of  which  is  by  no  means  easy  to  deter- 
mine. 

Lastly,  the  nerve  may  be  affected  after  its  exit  from 
the  stylomastoid  foramen.  This  is  the  most  common 
type,  and  is  known  as  "  Bell's  Palsy."  It  results  in 
wasting  and  paralysis  of  the  facial  muscles  without  any 
affection  of  taste,  hearing,  or  of  the  other  cranial 
nerves.  The  patient  is  unable  to  perform  any  of  the 
movements  depending"  upon  the  use  of  these  muscles 
on  the  affected  side,  such  as  smiling',  frowning,  closing 
the  eye,  whistling,  &c.  Mastication  is  interfered  with, 
and  food  tends  to  collect  between  the  teeth  and  the 
cheek  on  the  affected  side.  The  natural  wrinkles  are 
smoothed  out  upon  the  side  of  the  palsy.  The  tongue 
is  not  affected. 

It  will  be  seen  that  all  the  points  of  difference  de- 
scribed depend  upon  the  anatomical  course  and  relations 
■of  the  nerve,  and  a  knowledge  of  anatomy  will  there- 
fore enable  the  student  to  work  out  for  himself  the 
■clinical  picture  likely  to  be  present  in  any  given  case. 

The  following  tables  may  be  of  assistance :  — 

Table  I. 

Upper  Motor  Neuron.  Lower  Motor  Neuron. 

Paralysis  of  opposite  side  of  face—  Paralysis  of  same  side — 

Lower  half  of  face  chiefly  affected.  Upper  and  lower  halves  equally 

Emotional    movements     not    af-  affected. 

fected.  Voluntary  and    emotional  move- 

2^0  muscular  wasiing.  menis  equally  affected. 

JMo  change  in  electrical  reactions.  Muscular  wasting. 

Limbs  on  same  side  of  face  may  Reaction  of  degeneration. 

be  involved.  Limbs  on  opposite  side   of    face 

may  be  involved. 


INJURIES     AND     DISEASES     OF     NERVES 


67 


Table  II. 

Lower  Motor  Neuron. 


In  pons 

Hemiplegia  on 
opposite  side 
to  facial  palsy 
may  occur. 

Other  cranial 
nerves  affect- 
ed, especially 
sixth. 

Not  affected  as 
a  rule. 


Between  pons  and 
geniculate  ganglion 


T     T-  11      •  1       Outside  stylomastoid 

In  Fallopian  canal  foramen 


None. 


Not  as  a 
rule. 


Eighth  nerve 
usually  affected. 


Not  affected. 


Not  as  a  rule. 


Not  affected. 


Taste  unaffected. 


Taste  affected.        Taste  unaffected. 


Not  affected.  May  be  hyperacuity        Not  affected. 

ot  heating  to  low 
notes  if  lesion 
above  branch  to 
stapedius. 

The  prognosis  of  the  condition  depends  almost 
entirely  upon  the  cause  of  the  lesion.  The  rheumatic 
cases  as  a  rule  clear  up  completely  under  treatment, 
whereas  those  due  to  the  pressure  of  tumours  or 
general  nervous  disease  have  a  relatively  bad  pro- 
gnosis. 

The  treatment  of  the  condition  consists  in  the  re- 
moval of  the  cause.  In  the  rheumatic  cases,  treatment 
upon  the  lines  laid  down  under  Neuritis  {see  p.  62) 
should  be  pursued;  any  removable  source  of  irritation, 
such  as  an  mflamed  gland  or  diseased  tooth,  should  be 
dealt  with. 

In  cases  due  to  middle-ear  disease,  suitable  operative 
measures  must  be  employed. 

Nerve  anastomosis  has  been  undertaken  with  some 
success. 

Facial  Spasm,  or  Facial  Tic,  is  a  condition  of  spasm 
of  the  muscles  supplied  by  the  facial  nerve.  It  may 
be  due  to  peripheral  irritation,  such  as  dental  disease, 
inflamed  glands,  &c.,  to  emotional  disturbance,  such  as 
grief,  fright,  &c.,  or  to  pressure  upon  the  nerve  at  the 
base  of  the  skull  by  a  tumour.  In  some  cases  no  cause 
can  be  discovered  to  account  for  the  condition.  The 
spasms   are   usually   clonic   in   character,    and   may  in- 


68  SURGERY     FOR     DENTAL     STUDENTS 

volve  some  or  all  of  the  facial  muscles.  The  orbicularis 
palj)ebrarum  is  perhaps  most  frequently  affected,  whilo 
the  digastric,  stylohyoid  and  orbicularis  oris  often 
escape.  The  spasms  are  usually  unilateral  and  un- 
accompanied by  pain  or  tenderness. 

Diagnosis. — It  is  important  to  differentiate  those 
cases  in  which  some  gross  organic  lesion,  such  as  a 
neoplasm,  is  present  from  those  due  to  simple  irritation. 
In  the  former  case  the^  spasm  is  almost  always  accom- 
panied by  some  weakness  and  wasting  of  the  muscles 
involved,  and  the  limbs  are  usually  affected  as  well  as 
the  face. 

At  first  glance,  a  facial  spasm  on  the  right  side  may 
be  mistaken  for  a  left  facial  palsy.  On  examination, 
however,  it  will  be  found  that  the  apparently  palsied 
side  moves  perfectly  well. 

The  treatment,  of  course,  is  to  remove  the  cause,  if 
it  can  be  discovered  and  is  removable,  and  attention 
must  be  paid  to  the  general  health.  Drugs  are  not 
usually  of  value,  but  bromides,  combined  with  arsenic, 
may  be  useful.  Electrical  treatment  is  the  most  suc- 
cessful method^  as  a  rule.  Nerve  stretching  rarely 
gives  more  than  temporary  benefit. 

The  Hypoglossal,  or  Twelfth  Cranial  Nerve,  may  be 
affected  by  similar  causes  to  those  described  above. 
Wasting  and  weakness  of  one  side  of  the  tongue 
results,  so  that  the  tongue  when  protruded  points 
towards  the  paralyzed  side.  This  is  more  often  due 
to  intracranial  than  to  peripheral  causes,  and  may  form 
part  of  a  hemiplegia.  If  the  upper  neuron  is  affected 
wasting  will  not  occur,  and  the  electrical  reactions  will 
remain  unchanged. 

Treatment  must  be  directed  towards  the  underlying 
cause. 

The  spinal  nerves  may  be  affected  in  similar  ways, 
the  symptoms  depending  upon  the  anatomical  course 
and  distribution  of  the  nerve  involved.  Treatment 
should  be  carried  out  on  similar  lines  to  that  described 
above. 

Herpes  Zoster,  or  Shingles,  is  a  condition  the  phy- 
sical signs  of  which  make  their  appearance  in  the  skin. 
The  causative  lesion,  however,  is  a  haemorrhage  into 
the  posterior  root  ganglion  of  the  nerve  or  nerves  of 
supply   to  the   area   of   skin   affected.      Acute   pain   is 


INJURIES     AND     DISEASES     OF     NERVES  69 

felt  along  the  course  of  the  nerve.  This  is  followed  by 
some  hypersemia  of  the  affected  area  of  skin.  After 
a  day  or  two,  groups  of  greyish  yellow  vesicles  make 
their  appearance.  These  gradually  dry  up  and  disap- 
pear after  about  ten  days.  The  adjacent  lymphatic 
glands  are  often  enlarged.  In  certain  cases  no  pain 
whatever  is  present,  but  as  a  rule  it  is  severe.  The 
appearance  of  the  skin  lesion,  and  its  limitation  accord- 
ing to  the  cutaneous  nerve  supply,  should  be  sufficient 
to  make  the  diagnosis  of  the  condition  simple. 

Treatment  chiefly  aims  at  the  relief  of  symptoms. 
The  part  should  be  protected  from  irritation;  calamine 
lotion  or  boracic  powder  dusted  over  is  often  useful. 

Counter  irritation  to  the  nerve  trunk  by  means  of 
iodine,  blistering,  or  Antiphlogistine  may  be  used. 

Aspirin  or  phenacetin  may  be  given  for  the  pain, 
or,  if  necessary,  morphia.  Full  doses  of  tinct,  gelsemii 
may  do  good. 


CHAPTER    X. 
DISEASES  OF  TME  LYMPHATIC  SYSTEM. 

Lymphatic  Yessels. — Lymphangitis,  or  inflammation 
of  the  lymphatics,  may  be  acute  or  chronic. 

Acute  lymphangitis  is  almost  invariably  the  result  of 
septic  infection  from  a  wound.  The  wound  may  be  of 
the  most  trivial  character,  such  as  a  cut  finger,  or  an 
abrasion  caused  by  the  rubbing  of  an  ill-fitting  boot. 
The  condition  is  characterized  by  the  presence  of  red 
lines  running  along  the  course  of  the  main  lymphatic 
vessels  of  the  part,  and  associated  with  pain  and  swell- 
ing of  the  lymphatic  glands  into  which  the  affected 
vessels  drain.  As  a  rule,  the  infection  does  not  spread 
further  than  the  nearest  glands,  but  in  rare  cases 
general  septicemia  may  result.  If  a  large  number  of 
lymphatics  in  a  limb  are  affected,  the  separate  red  lines 
may  not  be  distinguishable,  the  whole  limb  being  red 
and  painful.  The  temperature  is  generally  slightly 
raised. 

Treatment. — First  remove  the  cause;  that  is  to  say, 
thoroughly  purify  the  wound  and  render  it  as  far  as 
possible  aseptic.  Keep  the  limb  at  rest,  and  apply  hot 
fomentations.  Administer  a  purge,  such  as  pil.  hydrarg. 
gr.  V  at  night,  followed  by  a  saline  in  the  morning. 
When  the  glands  are  very  painful,  but  not  suppurating, 
a  glycerine  of  belladonna  fomentation  may  give  relief. 
If  suppuration  occurs  the  abscess  must  be  opened,  the 
pus  evacuated,  and  fomentations  applied. 

Chronic  lymphangitis  usually  occurs  as  a  sequela 
of  the  acute  condition,  in  which  case  it  is  treated  on 
similar  lines.  Syphilitic  lymphangitis  occurs  most 
commonly  during  the  primary  stage  of  the  disease,  and 
affects  chiefly  the  lymphatics  of  the  penis.  It  should 
be  treated  by  antisyphilitic  remedies. 

Tuberculous  lymphangitis  also  occurs,  but  is  not 
common. 

Elephantiasis  is  a  chronic  hypertrophy  of  skin  and 
subcutaneous  tissue,  due  to  some  obstruction  to  the 
lymphatic  circulation.     Two  varieties  are  described:  — 


DISEASES    OF    THE    LYMPHATIC    SYSTEM  /I 

Elephantiasis  Arabum.  -In  tHis  condition  the  lymph- 
atic obstruction  is  due  to  a  parasite,  the  Filarla 
saHguinis  hominis.  It  is  not  necessary  to  deal  further 
with  this  condition. 

False  Elephantiasis. — Any  chronic  obstruction,  such 
as  the  pressure  of  a  tumour  or  glandular  disease,  may 
be  the  cause. 

The  treatuicjit  is  difficult  and  tedious.  The  limb 
should  be  kept  elevated,  and  an  elastic  bandage  applied. 
Certain  ingenious  operations  have  been  devised,  which 
have  afforded  relief  in  some  cases.  Lyniphangeioplasty 
is  the  formation  of  an  artificial  anastomosis  between 
the  lymphatic  vessels  and  the  venous  circulation  of  the 
part.  Artificial  lymphatics  have  also  been  formed  by 
means  of  sterilized  milk. 

A  lymphangeioma  is  a  new  grow^th,  consisting  of 
lymph  spaces  communicating  with  one  another  by 
means  of  lymphatic  channels,  which  may  either  be 
normal  lymphatics  dilated,  or  newly-formed  channels. 
They  are  usually  either  present  at  birth,  or  appear  soon 
after.  Three  kinds  of  lymphangeiomata  are  described, 
though  the  differences  between  them  are  merely  those 
of  degree  :  — 

(1)  A  capillary  lymphangeioma  (lymphatic  nsevus) 
consists  of  new-formed  lymphatics,  not  sufficiently 
dilated  to  form  cysts.  They  may  be  removed  either 
by  excision,  or  by  means  of  the  electric  cautery. 

(2)  A  cavernous  lymphangeioma. — There  are  a  large 
number  of  cysts  connected  together  by  lymphatics. 
Clinically,  they  appear  as  small  vesicles,  most  commonly 
upon  the  scrotum,  and  somewhat  resembling  Herpes, 
from  which,  however,  they  are  distinguishable  by  the 
absence  of  any  inflammatory  redness  of  the  surround- 
ing skin.     They  should  be  treated  by  excision. 

(3)  A  cystic  lymphangeioma,  or  cystic  hygroma,  is 
a  tumour  usually  of  considerable  size,  and  containing 
one  or  two  large  cystic  spaces,  which  do  not  always 
communicate.  The  most  common  situation  for  these 
tumours  is  about  the  side  of  the  neck. 

The  treatment  is  removal.  The  operation  may  be 
extremely  difficult,  as  these  tumours  often  extend 
deeply,  and  their  removal  involves  considerable  dis- 
section. 

Macroglossia  is  a  congenital  condition,  in  which  the 
tongue  is  enlarged  by  obstruction  to  the  flow  of  lymph, 


'J2  SURGERY    FOR    DENTAL     STUDENTS 

associated  with  hyperplasia  of  the  connective  tissue. 
The  tongue  is  at  first  soft,  but  is  very  liable  to  become 
inflamed;  after  two  or  three  attacks  of  inflammation  it 
may  become  quite  hard. 

TreaUnent. — Electrolysis  should  be  tried  first.  If 
this  fails,  operative  measures  {e.g.,  the  removal  of  a 
A^-shaped  portion  of  the  tongue)  will  be  required. 

Macrocheilia  is  a  similar  condition  involving  the  lip. 

Both  lips  may  be  affected,   but  the  lower  lip  is  most 

frequently  involved.     It  is  much  increased  in  size,  and 

^^        liangs   down.     In  this   condition  superficial  ulceration 

■of  the  mucous  membrane  frequently  occurs. 

Treatment. — Electrolysis  may  be  tried.  Excision  of 
the  affected  lip  will  usually  be  required. 

Lymphatic  Glands. 

Lymphadenitis,  or  inflammation  of  a  lymphatic 
gland,  may  be  acute  or  chronic. 

Acute  lymphadenitis  results  from  the  same  conditions 
as  acute  lymphangitis,  namely,  some  septic  focus 
which  may  be  quite  trivial.  The  gdands  in  the  neck 
and  axilla  are  commonly  affected,  the  disease  following 
\  on  such  conditions  as  discharge  from  the  ears,  oral 
sepsis,  or  pediculosis.  Lymphadenitis  may  also  occur 
as  a  complication  of  most  of  the  acute  specifics, 
notably,  scarlet  fever. 

The  disease  is  characterized  by  rapid  swelling  of  the 
gland,  accompanied  by  pain,  tenderness,  redness  of  the 
skin,  and  usually  some  fever.  Suppuration  often 
follows. 

The  treatment  is  similar  to  that  described  under 
lymphangitis.  Remove  the  septic  focus  on  which  the 
disease  depends,  open  the  abscess,  evacuate  the  pus, 
and  foment. 

Chronic  lymphadenitis  is  due  to  some  chronic  irri- 
tation. This  irritation  may  be  of  the  kind  described 
above  as  causing  the  acute  variety,  giving  rise  to  a 
simple  chronic  lymphadenitis,  or  it  may  be  tuberculous 
or  syphilitic. 

In  the  simple  variety  the  glands  are  swollen  and 
tender;  they  are  not  adherent  as  a  rule,  and  do  not 
commonly  suppurate. 

Treatment  should  include  rest  and  counter-irritation, 
such  as  painting  with  tincture  of  iodine.     If  suppura- 


DISEASES    OF    THE    LYMPHATIC    SYSTEM  73 

tion  occurs  fomentations  must  be  applied,  and  as  soon 
as  possible  the  pus  must  be  evacuated. 

Chronic  tuberculous  lymphadenitis  is  a  much  more 
common  condition,  especially  in  children  and  young 
adults. 

Among-  predisposing  causes  may  be  mentioned  over- 
crowding of  population  and  bad  or  insufficient  food. 
Glands  which  are  already  the  seat  of  a  simple  chronic 
inflammation  are  very  prone  to  become  tuberculous,  so 
that  careful  watch  must  be  kept  on  these  cases. 

The  glands  in  the  neck  are  perhaps  most  commonly 
the  seat  of  tuberculous  disease,  especially  those 
situated  in  the  anterior  triangle. 

The  clinical  manifestations  are  very  varied.  In  some 
cases  the  glands  are  small  and  liard,  with  little  or  no 
periadenitis  (inflammation  around  the  gland),  and  often 
no  signs  of  softening  until  the  late  stages  of  the 
malady.  The  diagnosis  from  lymphadenoma  (q.v.)  may 
be  difficult  in  this  type  of  case.  In  other  cases  the 
glands  rapidly  increase  in  size,  tending  to  soften  and 
suppurate  early;  there  is  much  periadenitis,  the  glands 
adhering  together  to  form  large  masses.  Abscesses 
often  point  and  discharge  on  the  surface,  thus  forming 
sinuses.  The  diagnosis  in  such  a  case  presents  no 
difficulty;  it  is  obviously  tuberculous.  Between  these 
two  extremes  there  are  many  clinical  varieties,  but  the 
chief  point  to  remember  is  that,  in  the  great  majority 
of  instances,   suppuration  occurs. 

Treatment  in  most  cases  must  be  operative.  When, 
however,  the  glands  are  small,  discrete  (not  adherent 
to  one  another),  and  not  rapidly  increasing  in  size,  the 
diagnosis  being  perhaps  doubtful,  it  may  be  justifiable 
to  delay  operation  and  to  try  the  effect  of  other  treat- 
ment. Complete  rest  of  the  affected  part  must  be 
ensured,  and  all  local  sources  of  irritation  removed. 
Plenty  of  fresh  air  and  good  food  is  essential.  Arsenic 
may  be  administered.  It  is  w^ell  to  begin  with  small 
doses,  such  as  liq.  arsenicalis  iij  minims,  which  may  be 
gradually  increased  up  to  viij  minims  or  more  three 
times  a  day.  Injections  of  tuberculin  have  also  been 
tried.  If  no  improvement  results  from  this  treatment, 
operation  must  not  be  long  delayed — not  longer  than 
about  three  months.  If  suppuration  occurs,  or  if  there 
is  any  rapid  increase  in  size  in  the  glands,  immediate 
operation  is  indicated. 


74  SURGERY     FOR     DENTAL     STUDENTS 

It  is  essential  that  the  operative  measures,  when  em- 
ployed, should  be  as  thorough  as  possible,  even 
though,  as  is  often  the  case,  very  deep  dissection  is 
necessary  to  remove  the  glands  completely. 

Syphilis  may  affect  the  lympjiatic  glands  in  any  of  its 
three  stages.     (Vide  Syphilis,  Chapter  XII.) 

Lymphadenoma. — This  disease  is  most  commonly 
met  with  m  young  adult  males;  women  are  much  less 
frequently  affected;  it  is  occasionally  met  with  in 
children. 

The  clinical  signs  of  the  malady  are  :  increase  in  size 
of  the  lymphatic  glands  all  over  the  body,  but  chiefly 
those  in  the  neck  and  groin,  associated  with  enlarge- 
ment of  the  spleen,  and  often  of  the  liver  also. 

"The  glands  at  first  are  softish,  discrete,  and  pain- 
less; later,  they  become  harder  and  coalesce.  They 
do  not  suppurate. 

Diagnosis. — The  presence  of  several  groups  of 
enlarged  glands,  the  enlarged  spleen,  and  the  absence 
of  suppuration  are  the  points  to  be  relied  on  in  differen- 
tiating between  this  condition  and  tuberculous  disease. 
The  fact  that  there  is  no  infiltration  of  surrounding 
tissues  and  the  slow  increase  in  size  of  the  tumour 
are  points  in  favour  of  lymphadenoma  as  opposed  to 
lymphosarcoma.  Microscopical  examination  may  be 
necessary  in  doubtful  cases. 

Treatment. — Treatment  on  general  hygienic  lines, 
similar  to  those  laid  down  in  discussing  tuberculous 
glands,  should  be  employed.  Gradually  increasing 
doses  of  arsenic  should  be  given.  Salvarsan  ("  606  ") 
has  been  tried,  but  opinions  are  divided  as  to  its  value. 
Operative  treatment  is  of  no  value,  as  recurrence 
always  takes  place. 

A  Lymphosarcoma  is  a  rapidly  growing,  malignant 
tumour;  microscopically  it  resembles  very  closely  a 
small  round-celled  sarcoma.  At  first  it  is  usually  pain- 
less, but  later  becomes  tender,  and  causes  pain  from 
pressin"e.  It  rapidly  infiltrates  surrounding  tissues, 
and  sooner  or  later  involves  the  skin.  Secondary 
deposits  occur  in  neighbouring  glands. 

The  only  hope  of  relief  lies  in  immediate  and  com- 
plete extirpation,  but  recurrence  is  common. 

Secondary  Carcinomata  are  common. 

Secondary  Sarcomata  are  very  rare,  except  lympho- 
sarcomata.     (Vide  supra.) 


CHAPTER    XL 
DISEASES    OF    DUCTLESS    GLANDS. 

For  the  purpose  of  this  handbook  only  two  of  the 
ductless  glands  need  claim  attention,  ?y/^.,  the  thyroid 
and  the  pituitary  body. 

Diseases  of  the  Thyroid  Body. 

Congenital  absence  of  the  thyroid  body  results  in  a 
curious  condition  known  as  Cretinism ;  atrophy  of  the 
thyroid  results  in  Myxoedema.  Both  these  conditions, 
especially  the  former,  have  been  successfully  treated 
by  the  administration  of  thyroid  extract.  For  a  de- 
scription of  cretinism  and  myxcedema  a  larger  text- 
book should  be  consulted. 

Acute  thyroiditis  is  a  rare  condition,  usually  traceable 
to  rheumatism,  exposure  to  cold,  or  to  septic  infection. 

The  thyroid  is  slightly  enlarged  and  painful,  the  skin 
over  it  red  and  inflamed;  there  may  be  some  difficulty 
in  swallowing.  Severe  constitutional  disturbance  may 
occur,  especially  Avhen  in  the  septic  variety  suppuration 
supervenes. 

Treatment. — A  glycerine  of  belladonna  fomentation 
should  be  applied  locally;  a  smart  purge  should  be 
administered,  and  in  rheumatic  cases  sodium  salicylate 
should  be  given.  If  suppuration  occurs,  the  abscess 
should  be  opened  at  once. 

A  non-inflammatory  enlargement  of  the  thyroid  body 
is  spoken  of  as  goitre,  or  bronchocele.  There  are 
several  varieties,  and  they  are  difficult  to  classify  on 
account  of  the  resemblance  between  them. 

First,  they  may  be  divided  into  two  classes  :  — 

(i)  Enlargements  of  the  gland  as  a  wdiole. 

(ii)  Tumours  in  the  substance  of  the  gland. 

These  two  types  of  enlargement  are  frequently  co- 
existent in  the  same  patient.  It  will  be  convenient, 
however,  to  describe  them  separately. 

(i)  Enlargement  of  the  gland  as  a  whole. 


76  SURGERY     FOR     DENTAL     STUDENTS 

(d)  Simple  Parenchymatous  Goitre. —  In  this  con- 
dition there  is  a  general  enlargement  of  the  thyroid, 
in  which  all  the  tissues  of  the  gland  participate.  (It 
may  be  confined  to  one  lobe.)  In  some  cases  this 
enlargement  is  accompanied  by  marked  increase  in  the 
quantity  ot  colloid  material  present.  These  cases  are 
called  Colloid  Goitres. 

The  enlargement  of  the  gland  is  found  to  be  uniform, 
rather  soft,  and  free  from  pain  and  tenderness.  The 
surface  of  the  tumour  is  smooth,  unless  adenomata  are 
present  as  well.  Various  symptoms  may  arise  from 
pressure  of  the  tumour  upon  neighbouring  structures, 
e.g.,  dysphagia  from  pressure  upon  the  oesophagus, 
aphonia  from  irritation  of  the  recurrent  laryngeal  nerve, 
or  dyspnoea  if  the  trachea  be  pressed  upon.  In  the  later 
stages  the  superficial  veins  running  over  the  tumour 
may  be  enlarged,  and  cystic  degeneration  may  occur  in 
the  tumour. 

Treatment. — In  the  early  stag'es  attention  must  be 
paid  to  the  general  health,  and  potassium  iodide  may  be 
administered,  commencing  with  gr.  iii,  and  gradually 
increasing  the  dose  up  to  gr.  xv,  if  no  toxic  symptoms 
are  caused.  Thyroid  extract  is  rarely  of  any  value.  If 
this  treatment  fails  to  check  the  disease,  operative  treat- 
ment, i.e.,  H eviithyroide ctomy  (removal  of  half  of  the 
gland)   may  be  required. 

{b)  Exophthalmic  Goitre,  or  Graves's  disease,  is  a 
condition  in  which  uniform  enlargement  of  the  thyroid 
gland  is  associated  with  exophthalmos  (protrusion  of 
the  eye),  and  certain  other  characteristic  symptoms. 

The  disease  often  follows  some  sudden  nervous 
shock,  and  is  probably  due  to  increased  secretion  from 
the  gland.  Women  are  more  often  affected  than  men, 
the  typical  patient  being  a  girl  of  from  18  to  25. 

The  thyroid  enlargement  is  usually  uniform  and  soft, 
the  tumour  varying  considerably  in  size.  It  is  rarely 
painful.  In  some  cases  adenomata  occur  as  well, 
giving  rise  to  an  irregular  enlargement.  Cases  also 
occur  in  which  the  thyroid  is  small  in  size  and  hard  in 
consistence,  but  this  is  uncommon. 

The  chief  signs  of  the  disease,  in  addition  to  the 
thyroid  tumour,  are:  — 

Exophthalmos,  of  prominence  of  the  eyeballs. 
Usually   this    is    quite    obvious    from    looking    at    the 


DISEASES     OF     DUCTLESS     GLANDS  "JJ 

patient,  but  there  are  certain  signs  which  confirm  it. 
If  the  patient  is  told  to  look  at  the  surgeon's  finger, 
held  about  a  yard  away,  and  then  the  finger  is  slowly 
moved  downwards,  it  will  be  found  that,  though  the 
patient's  eyes  follow  the  finger,  the  upper  lids  lag  be- 
hind in  a  characteristic  manner.  This  is  known  as  von 
Graefe's  sign. 

Taclixcardia  (increased  rapidity  of  the  heart's  action). 
— This  is  often  considerable,  and  may  be  a  most  dis- 
tressing feature  of  the  malady,  giving  rise  to  severe 
palpitations. 

I^iiie    tremor   of   the    hngers    is    frequently   present. 

These  four  signs — Thyroid  enlarg'ement,  Exophthal- 
mos, Tachycardia,  and  Tremor — are  known  as  the  four 
cardinal  signs  of  Graves's  disease. 

In  addition  to  these  four  cardinal  signs,  there 
is  usually  considerable  nervousness  and  excitability, 
sleeplessness,  and  slight  anaemia.  Amenorrhoea  may 
be  present. 

Treatment. — At  first  the  treatment  should  be  medical, 
and  should  include  rest,  absence  of  worry  and  anxiety, 
as  far  as  possible,  and  avoidance  of  all  excitement. 
Drugs  may  be  prescribed  as  the  symptoms  demand, 
viz.,  iron  and  arsenic  for  the  anaemia,  digitalis  (dose 
5  to  10  minims)  if  the  tachycardia  be  extreme,  and  bro- 
mides for  the  sleeplessness.  Thyroid  extract  does  harm, 
not  good,  and  should  not  be  given.  In  obstinate  cases, 
hemithyroidectomy  has  been  performed  with  some 
success. 

Enlargement  of  the  thyroid  is  of  g'rave  significance 
in  regard  to  the  administration  of  a  general  anaesthetic, 
and  should  always  be  brought  to  the  attention  of  the 
anaesthetist. 

(ii)  Tumours  in  the  Gland. 

{a)  Adenomata  may  be  single  or  multiple.  Their 
presence  may  be  recognized  by  the  irregular,  nubbly 
feeling  of  the  gland,  but  in  all  cases  where  there  is 
considerable  enlargement  of  the  gland  the  adenomata 
will  probably  be  found  to  be  associated  with  colloid 
goitre. 

Treatment  is  always  operative.  Single  adenomata 
may  be  shelled  out,  but  when  multiple,  hemithyroidec- 
tomy will  usually  be  required. 

[b]  Carcinoma    of   the   thyroid   occurs   as  a   rapidly 


J 


78  SURGERY     FOR     DENTAL     STUDENTS 

growing",  extremely  Iiard  tumour  with  an  irregular 
surface,  which  usually  ulcerates  early.  The  surrounding 
tissues  are  rapidly  infiltrated  by  the  growth,  while 
severe  symptoms  usually  result  from  pressure  of  the 
growth  upon  neighbouring  organs.  Cachexia  is 
usually  marked,  while  secondary  growths  are  formed 
early,  the  long  bones  being  a  frequent  seat  of  secondary 
deposits. 

Treatment. — In  very  early  stages  it  may  be  possible 
to  extirpate  the  whole  of  the  growth,  but  as  the  whole 
gland  must  be  removed  for  the  treatment  to  be  of  any 
value,  myxoedema  will  supervene  unless  the  patient  be 
treated  with  thyroid  extract  for  the  rest  of  his  life. 

In  later  stages  treatment  is  solely  directed  towards 
the  relief  of  symptoms.  Tracheotomy  may  be  required 
if  dyspnoea  is  severe. 

(c)  Sarcoma  is  not  so  common  as  carcinoma.  It 
is  most  usually  unilateral,  and  is  of  a  very  rapid  type. 
Operative  treatment  is  required,  as  in  carcinoma. 

Diseases  of  the  Pituitary  Body. 

The  only  disease  known  to  be  connected  with  this 
gland  is  Acromegaly.  Our  knowledge  of  this  malady 
has  been  considerably  increased  by  the  recent  re- 
searches of  Professor  Arthur  Keith.  It  is  only  possible 
here  to  touch  upon  the  subject  quite  briefly,  but  those 
students  who  desire  a  fuller  acquaintance  with  the 
disease  will  be  amply  repaid  by  studying  Professor 
Keith's  paper,  published  in  the  Lancet  of  April  15, 
191 1,  free  use  of  which  is  made  in  the  following  pages. 

Acromegaly  is  a  disease  characterized  by  overgrowth 
of  the  bones  in  various  parts  of  the  body.  Its  chief 
interest  to  dental  students  lies  in  the  great  changes 
which  take  place  in  the  lower  jaw. 

It  has  been  shewn  that  the  malady  depends  upon 
some  abnormal  condition  of  the  pituitary  body. 
Acromegalic  skulls  show  by  the  enlargement  of  the 
pituitary  fossa  that  the  glandular  portion  must  have 
been  the  seat  of  a  tumour,  the  size  of  the  enlargement 
varying  in  different  skulls. 

The  bony  changes  which  occur  appear  to  be  de- 
pendent upon  a  hypersecretion  from  the  enlarged 
pituitary  body. 


DISEASES     OF     DUCTLESS     GLANDS  79 

The  physiological  function  of  the  glandular  portion 
has  been  shewn  by  Professor  Keith  to  be  connected 
with  the  normal  growth  of  the  skeleton.  The  pituitary 
secretion  acts  upon  the  osteoblasts;  it  does  not  actually 
Stimulate  them  into  activity,  but  it  makes  them  sensitive 
to  certain  other  stimuli,  namely,  increasing  muscular 
development.  The  actual  stimulus  to  bony  growth 
comes  from  the  muscle,  but  the  pituitary  secretion  is 
required  in  order  that  the  osteoblasts  may  be  ready  to 
respond  to  this  stimulus. 

Normally,  wdien  adult  life  is  reached,  bony  growth 
practically  ceases.  In  the  disease  under  discussion  the 
pathological  condition  present  in  the  pituitary  body 
starts  the  process  again.  The  overgrowth  that  occurs 
in  the  bones  in  acromegaly  is  an  overgrowth  of  normal 
bone  laid  down  by  means  of  the  normal  process;  it 
occurs  in  the  places  where,  from  the  foregoing  pages, 
it  would  be  expected  to  occur,  vis.,  in  positions 
affected  by  muscular  traction,  which  has  been  said  is 
the  normal  stimulus  of  bony  growth. 

Professor  Keith  also  shews  that  there  is  considerable 
resemblance  between  acromegalic  skulls,  skulls  of  the 
Neanderthal  type,  and  those  of  the  anthropoid  apes, 
especially  the  gorilla.  He  suggests  that  there  is 
strong  reason  for  supposing  that  a  condition  of  hyper- 
pituitarism, i.e.,  hypersecretion  from  the  pituitary 
body,  w'as  present  in  the  Neanderthal  man  and  still  is  so 
in  the  gorilla. 

What  the  cause  of  this  abnormal  enlargement  of 
the  pituitary  body  may  be  remains  at  present  a  mystery. 
It  is  known  that  the  pituitary  secretion  can  be  increased 
by  castration  and  thyroidectomy,  and  that  it  is  increased 
during  pregnancy. 

Changes  in  the  Mandible. — Considerable  overgrowth 
takes  place  in  the  low^er  jaw,  especially  affecting  the 
ascending  ramus,  which  is  narrowed  and  elongated, 
so  that  the  angle  is  depressed  and  the  chin  pushed 
forward ;  there  is  also  new  bone  formed  in  the  region 
of  the  chin.  Grow^th  also  occurs  at  the  coronoid  and 
condylar  processes.  Thus  it  will  be  seen  that  growth 
occurs  at  points  exposed  to  muscular  traction. 

Changes  in  the  Temporomaxillary  Joint. — Growth 
occurs  in  the  glenoid  cavity,  its  floor  being  thickened 
and  filled  up,  so  as  to  bring  it  almost  level  with  the 
articular  eminence. 


8o  SURGERY    FOR    DENTAL    STUDENTS 

Many  other  changes  occur,  both  in  the  bones  of  the 
head  and  of  the  hmbs,  especially  in  the  extremities, 
that  is,  the  fingers  and  the  toes,  but  the  foregoing  will 
suffice  to  show  the  general  result. 

The  patient  usually  suffers  from  headache,  neuralgic 
pains,  and  lassitude,  and  is  often  weak-minded. 

Treatment. — Operative  treatment  for  the  removal  of 
the  glandular  portion  of  the  pituitary  body  has  been 
recommended.  But  every  experimental  operation  of 
this  nature  upon  animals  has  proved  fatal. 

Apart  from  operation,  treatment  must  be  merely 
symptomatic.  Antipyrine,  caffeine,  or  even  morphia, 
may  be  required  for  the  relief  of  the  pain. 

Pituitary  extract  has  been  given  without  success. 
Indeed,  if  the  disease  be  due  to  hypersecretion  from 
the  gland,  further  injection  of  the  extract  of  that 
gland  would  not  appear  likely  to  have  beneficial  effect. 
Thyroid  extract  has  also  been  given,  without  any 
marked  benefit. 


CHAPTER    XII. 
SPECIFIC    INFECTIVE    DISEASES. 

Erysipelas. 

Erysipelas  is  an  infective  disease,  involving  chiefly 
the  skin  and  mucous  membrane. 

Considerable  differences  of  opinion  have  existed  as 
to  whether  the  micro-organism  to  which  the  disease  is 
due  is  a  specific  bacterium  or  whether  it  is  identical 
with  the  Streptococcus  pyogenes.  At  one  time  several 
important  differences  were  said  to  exist  between  the 
two  organisms,  and  a  special  name,  5.  erysipelatis,  was 
given  to  the  erysipelas  organism.  Nowadays,  the 
majority  of  observers  are  of  opinion  that  the  so-called 
vS.  erysipelatis  is  merely  5.  pyogenes  of  a  particular 
degree  of  virulence.  The  differences  in  the  clinical 
manifestations  of  the  two  infections  are,  however, 
sufficient  to  justify  the  inclusion  of  erysipelas  for 
descriptive  purposes  among  the  specific  infections. 

The  streptococcus  gTows  readily  on  all  the  ordinary 
media,  stains  well  with  simple  stain  and  by  Gram's 
method.  In  the  great  majority  of  cases,  an  obvious 
though  often  quite  small  wound  is  present  through 
which  infection  occurs.  In  a  few  instances  a  so-called 
idiopathic  variety  occurs  in  which  no  wound  can  be 
detected.  In  all  probability  infection  in  these  cases 
occurs  either  through  an  undetected  wound,  or  else 
through  one  of  the  hair  follicles.  It  is  significant  that 
the  g-reat  majority  of  cases  of  idiopathic  erysipelas 
occur    on    the    scalp. 

The  incubation  period  is  short,  vis.,  a  few  hours  to 
three  days.  The  early  symptoms  are  of  the  common 
febrile  type,  such  as  headache,  malaise,  general  aching* 
pains,  slight  fever,  and  sometimes  a  slight  rigor.  The 
pulse  is  generally  full,  the  tongue  dry  and  furred, 
and  the  bowels  constipated. 

The  wound,  if  present,  has  an  unhealthy  appearance, 
and  after  about  twenty-four  hours  a  rash  appears 
which  spreads  outwards  from  the  edges  of  the  wound. 
6 


^2  SURGERY    FOR    DENTAL    STUDENTS 

The  rash  is  bright  red  in  colour,  and  disappears  on 
pressure;  the  edges  are  sHghtly  raised.  There  is  a 
sensation  of  burning  irritation  in  the  part.  There  is 
not,  as  a  rule,  much  oedema,  except  in  certain  situa- 
tions which  favour  it,  such  as  the  scrotum,  eyelids,  &c. 
As  the  rash  spreads  outwards  it  disappears  from  the 
centre,  often  with  fine  desquamation.  The  neighbour- 
ing lymphatic  glands  are  frequently  enlarged,  and  red 
lines  are  often  seen  along  the  course  of  the  lymphatic 
vessels. 

In  severe  cases,  especially  when  the  scalp  is  affected, 
there  may  be  high  fever  and  delirium. 

Sometimes  the  subcutaneous  tissues  are  involved  in 
the  infection,  diffuse  suppuration  taking  place.  This 
condition  is  termed  cellulo   cutaneous  erysipelas. 

Suppuration  and  great  oedema  frequently  accompany 
facial  and  scrotal  erysipelas. 

Infection  may  spread  by  means  of  the  veins  to  in- 
ternal organs.  Notably  is  this  the  case  when  the  head 
or  face  is  affected,  the  meninges  being  then  in  great 
danger. 

The  diagnosis  is  usually  easily  made  from  the  appear- 
ance and  mode  of  spread  of  the  rash  and  the  rapidity 
of  onset. 

Ophthalmic  Herpes  is  often  mistaken  for  facial 
erysipelas.  If  it  is  borne  in  mind  that  ophthalmic 
herpes  is  always  unilateral  and  facial  erysipelas  always 
bilateral  this  mistake  will  not  be  made. 

Treatment. — The  patient  should  be  isolated;  if  in 
hospital,  separate  nurses  and  dressers  should  be  told 
off  to  attend  the  case.  To  prevent  the  spread  of  the 
disease  on  the  surface,  a  ring  of  iodine  liniment,  or 
nitrate  of  silver  5ss  ad.  ji  should  be  painted  round 
on  the  healthy  skin,  just  beyond  the  edge  of  the  affected 
area.  A  dressing  of  ichthyol  ointment,  frequently 
applied,  seems  to  give  the  best  results.  Antistrepto- 
coccic serum  has  been  used,  but  the  results  have  not 
been  encouraging. 

Quinine  should  be  given  in  doses  of  gr.  iij  three  times 
a  day,  and  saline  purges  for  the  constipation.     Tinct. 
ferri.  perchlor.  in  doses  5ss  three  times  a  day  is  said 
;to  have  a  specific  action. 

Plenty  of  nourishment  should  be  given. 

Where   suppuration   has   occurred,   especially  in  the 


SPECIFIC  INFECTIVE  DISEASES  83 

cellulo-cutaneous  form,  free  incisions  should  be  made 
and  fomentations  applied. 

When  the  fauces  are  involved,  frequent  spraying  of 
the  Dart  with  liq.  sodse  chlorinatae  5ss  ad.  Ji  is  use- 
ful. 'Tracheotomy  may  be  required,  if  there  is  much 
oedema. 

Tetanus. 

The  direct  exciting  cause  of  tetanus  is  infection 
by  the  Bacillus  tctani  (fig.  8).  It  is  a  slender,  rod- 
shaped  organism,  about  4  fx  to  5  ^  in  length.  It 
is  motile,  and  possesses  numerous  flagella  at  both 
ends  and  at  the  sides.  It  stains  with  simple  stains, 
and  by  Gram's  method.  It  is  an  anaerobic  organism. 
it  grows  well  on  the  ordinary  culture  media  if  oxygen 


Fig.  8. — Bacillus  tetani 
(shewing  spores). 

be  excluded.  It  forms  spores,  which  are  placed  at  one 
end,  giving  the  bacillus  a  characteristic  appearance 
which  has  been  likened  to  a  drumstick.  These  spores 
are  very  resistant  to  antiseptics ;  boiling  for  five  minutes 
is  not  always  sufficient  to  destroy  them.  Some  abrasion 
of  the  skin  is  necessary  to  allow  the  organism  to  gain 
access  to  the  body.  Wounds  made  with  dirty  instru- 
ments, especially  with  earth  or  dirt  from  the  streets, 
are  those  most  frequently  followed  by  infection  with 
tetanus.  The  tissues  are  generally  in  a  state  of  de- 
pressed vitality  from  sepsis  or  other  cause;  in  fact, 
pyogenic  organisms  are  almost  invariably  present. 

Tetanus  is  naturally  more  common  among  those 
whose  occupation  renders  them  liable  to  wounds  of  this 
character,  such  as  agricultural  labourers,  stablemen. 
&c.       The    organisms    are    found    only    in    the    local 


84  SURGERY  FOR  DENTAL  STUDENTS 

lesion;  they  do  not  enter  the  blood-stream,  but  act 
entirely  by  means  of  their  toxins.  These  toxins  have 
a  specific  action  upon  the  motor  cells  in  the  spinal  cord, 
medulla  and  pons,  and  to  a  less  extent  upon  those  in 
the  cerebral  cortex.  Tetanus  toxin  is  peculiar  in  that 
it  passes  not  by  the  blood-stream  nor  the  lymphatics, 
but  along  the  nerves.  Marie  and  Morax  have  shewn 
that  the  toxins  are  absorbed  by  the  nerve  end  plates 
in  the  muscles,  and  carried  along  tlie  motor  nerve 
filaments.  They  do  not  appear  ever  to  pass  along  a 
purely  sensory  nerve. 

Clinical  signs. — The  incubation  period  varies  within 
wide  limits.  In  this  country  it  is  usually  from  two  to 
three  weeks.  Abroad,  it  is  often  much  shorter,  some- 
times only  a  few  hours.  The  severity  of  the  attack  is 
roughly  proportional  to  the  shortness  of  the  incuba- 
tion. 

The  disease  commences  with  slight  fever  and  diffi- 
culty in  opening  the  mouth.  This  is  followed  by  pain 
and  stiffness  in  the  muscles,  commencing  w^ith  the 
masseter,  internal  pterygoid,  and  small  facial  muscles, 
the  sternomastoid  and  trapezius  being  involved  slightly 
later.  As  the  disease  progresses  muscular  spasms 
occur,  spreading  downwards  to  the  trunk  and  limbs. 
The  hands  are  seldom  affected,  and  involvement  of  the 
respiratory  muscles  is  usually  quite  a  late  phenomenon. 
Great  pain  is  experienced  during  the  spasms,  which  are 
typically  of  a  tonic  (continuous)  character;  clonic 
spasms  may  also  occur  as  well  in  the  later  stages. 
There  is  never  complete  relaxation  between  the 
spasms,  and  the  intervals  of  partial  relaxation  become 
gradually  shorter.  Any  stimulus,  such  as  a  cold 
draught  of  air  or  a  sudden  noise,  tends  to  start  a 
spasm. 

The  contraction  of  certain  groups  of  muscles  may 
cause  the  patient  to  assume  characteristic  attitudes. 
The  body  may  be  bent  backwards  (opisthotonos)  or 
forwards  (emprosthotonos),  or,  more  rarely,  sideways 
(Mcurosthotonos).  The  angles  of  the  mouth  are  often 
retracted,  giving  rise  to  a  sort  of  grinning  expression 
(risus  sardonicus). 

The  mind,  as  a  rule,  is  clear  to  the  end,  and  the 
sufferings  of  the  patient  are  very  great.  The  tempera- 
ture,   which  during  the  course  of  the  malady  is  little 


SPECIFIC  INFECTIVE  DISEASES  85 

if  at  all  above  normal,  may  rise  to  extreme  heights 
{e.g.,  108°  F.j  just  before  death.  Death  is  usually 
due  to  exhaustion;  sometimes  to  involvement  of  the 
respiratory  muscles. 

A  more  chronic  form  of  tetanus  sometimes  occurs, 
in  which  the  spasms  are  less  severe  and  often  limited  to 
certain  muscles,  especially  those  of  mastication.  The 
incubation  period  is  usually  three  weeks  or  more  in 
these  cases.  Recovery  is  much  more  frequent  than  in 
the  acute  form,  often  occurring  without  treatment. 

A  special  form  of  tetanus,  cephalic  tetanus,  occasion- 
ally follows  injuries  of  the  head.  It  differs  from  the 
usual  form  in  that  facial  palsy  is  a  common  accompani- 
ment, and  severe  maniacal  symptoms  occur. 

In  newly-born  infants  infection  may  occur  through 
the  umbilical  cord.     It  is  usually  rapidly  fatal. 

The  diagnosis  of  tetanus  is  not  usually  difficult. 
The  conditions  which  may  simulate  it  are  :  strychnine 
poisoning,  hydrophobia,  tetany,  and  simple  trismus. 
In  strychnine  poisoning  there  is  complete  relaxation 
between  the  spasms,  and  the  extremities  are  chiefly 
involved.  Trismus  is  rare.  The  history  may  clinch 
the  diagnosis. 

In  hydrophobia  the  mental  symptoms  are  very 
characteristic,  t'z^.,  vague  fears  and  hallucinations. 
The  spasms  are  clonic  in  character;  there  is  marked 
salivation.  The  history  may  be  of  value.  Tetany  is 
almost  entirely  confined  to  the  hands  and  feet.  It 
occurs  most  frequently  in  children.  When  adults  arc 
affected  it  is  usually  during  the  course  of  acute  gastric 
or  intestinal  irritation,  and  is  hardly  likely  to  be  mis- 
taken for  tetanus. 

In  simple  trismus  due  to  the  irritation,  e.g.,  of  a 
tooth,  the  muscles  of  mastication  are  the  only  ones 
affected. 

Treatment. — Prophylactic  treatment  is  of  the  first 
importance;  absolute  asepsis,  as  far  as  can  be  obtained 
in  all  wounds,  w^hether  suspicious  or  not,  is  of  the 
greatest  value  in  providing  against  the  infection. 

When  an  attack  has  occurred  treatment  must  be 
immediate.  Tetanus  toxin  combines  very  rapidly  with 
the  protoplasm  of  the  cells;  and  when  this  combination 
has  taken  place,  further  treatment  is  of  little  avail. 
The  local  wound  must  be  purified  to  prevent  further 


86  SURGERY  FOR  DENTAL  STUDENTS 

manufacture  of  toxins  by  the  bacteria.  An  attempt  to 
neutralize  the  toxins  ahxady  present  in  the  blood 
should  be  made  by  injecting  a  suitable  dose  of  anti- 
tetanic  serum.  The  results  have  been  by  no  means  so 
encouraging"  as  those  obtained  with  antidiphtheric 
serum.  This  is  no  doubt  due  to  the  rapidity  with 
which  combination  takes  place  between  the  toxin  and 
the  cells. 

The  antitetanic  serum  is  now  sometimes  injected 
direct  into  the  spinal  canal.  The  rapidity  with  which 
the  serum  acts  is  thus  increased. 

Excretion  should  be  assisted  'by  diuresis  and  purging. 
Saline  infusion  is  often  of  value. 

All  possible  stimuli  should  be  avoided;  the  room 
should  be  darkened,  no  draughts  allowed,  and  absolute 
quiet  enjomed. 


Fig.  9. — Bacillus  anthracis 
shewing  arrangement  in  cliains  and  spores). 

To  check  the  spasms,  the  best  drug  is  chloroform; 
large  doses  of  chloral  hydrate  may  be  given,  say 
gr.  XX  combined  with  potassium  bromide  5i  every 
hour;  if  the  patient  cannot  swallow,  this  should  be 
given  by  the  rectum.  The  dose  should  then  be 
doubled. 

Anthrax. 

Anthrax  is  a  disease  affecting  sheep  and  cattle,  and 
is  occasionally  transmitted  from  these  animals  to  man. 
Those  who  attend  to  the  live  animals,  or  who  have  to 
do  with  carcases  or  hides  and  wool,  are  specially  liable. 
The  exciting  cause  of  the  disease  is  the  B.  anthracis 
(fig.  9j.  This  is  a  rod-shaped  organism,  about 
(S  yL6  to  10  /u,  in  length  ;  it  grows  well  on  ordinary 
media;   and    stains   with    simple    stain   and   by    Gram's 


SPECIFIC  INFECTIVE  DISEASES  8/ 

method.  The  organism  forms  spores  which  are 
situated  in  the  centre.  These  spores,  Hke  those  of 
tetanus,  are  very  resistant  to  antiseptics,  and  must  be 
boiled  for  15  minutes  in  order  to  be  destroyed  with 
certainty. 

Anthrax  may  occur  in  man  either  as  a  local  lesion 
with  subsequent  general  symptoms,  or  as  a  generalized 
infection  without  a  local  lesion. 

The  local  lesion  is  known  as  Malignant  pustule. 
After  an  incubation  period,  which  varies  from  a  few 
hours  to  two  or  three  weeks,  a  small  red  papule  appears 
at  the  seat  of  infection,  commonly  on  the  hands,  arms, 
face  or  neck.  This  is  generally  preceded  by  itching 
and  burning  sensations.  The  papule  soon  becomes  a 
vesicle  containing  usually  blood-stained  serum;  this 
ruptures,  and  a  black  gangrenous  patch  forms  in  the 
centre,  around  which  a  ring  of  new  vesicles  forms, 
surrovmded  in  their  turn  by  a  ring  of  red  and  inflamed 
tissue.  The  black  centre  progressively  enlarges  at  the 
expense  of  the  surrounding  vesicles;  at  the  same  time 
new  vesicles  are  formed  outside  it.  In  some  cases  the 
spread  is  very  rapid,  in  others  more  gradual. 

General  symptoms  make  their  appearance,  as  a  rule, 
as  soon  as  the  black  patch  shows.  These  are:  fever, 
headache,  vomiting,  general  glandular  swelling,  and 
deep-seated  pains  all  over  the  body.  If  untreated, 
coma  and  death  follow. 

The  treatment  is  immediate  excision  of  the  malig- 
nant pustule,  taking"  care  to  remove  all  diseased  tissue, 
and  to  go  as  deep  as  possible.  The  actual  cautery 
may  be  applied.  Some  authorities  deny  that  anything 
is  gained  by  incision  of  the  local  lesion,  and  advise 
treatment  by  means  of  fomentations.  Serum  treat- 
ment is  also  practised  in  this  disease. 

Anthracsemia,  or  Woolsorters'  Disease,  is  a  gene 
ralized  infection  with  anthrax  bacilli,  the  organisms- 
being  either  inhaled  or  swallowed.  In  the  former  case 
the  lungs  are  chiefly  involved,  with  signs  of  rapid  pneu- 
monia; in  the  latter  the  gastro-intestinal  tract  is 
attacked,  giving  rise  to  severe  diarrhoea,  vomiting,  &c. 
General  glandiilar  swelling  occurs  in  both  varieties. 
The  disease  is  extremely  fatal. 

Treatment. — A  fatal  issue  occurs  so  rapidly,  as  a 
rule,  that  there  is  rarely  time  for  treatment.  Serum 
treatment  has  met  with  some  success. 


88  SURGERY    FOR    DENTAL    STUDENTS 

GONORRHCEA. 

Gonorrhoea  is  an  infective  inflammation  due  to  the 
go  no  CO  ecus.  It  may  occur  in  either  sex,  and  follows 
coitus.  The  Diplococciis  gonorrhcecB,  or  gonococcus 
(fig.  lo),  occurs  in  pairs.  Each  organism  is  not  per- 
fectly spherical,  but  the  side  turned  towards  its  com- 
panion coccus  is  somewhat  flattened.  It  is  difficult  to 
grow,  blood-agar  being  tlie  best  medium.  It  stains 
well  with  basic  aniline  dyes,  but  not  by  Grain's  method. 

The  incubation  period  of  the  disease  is  from  two  to 
eight  days.  In  the  male  it  commences  with  scalding 
pain  on  micturition,  which  has  been  compared  by  one 
imaginative  patient  to  "  passing  red-hot  fish-hooks." 
There  is  often  some  swelling-  and  tenderness  of  the 
meatus.      The    urethral    discharge    appears    about    the 


Fig.  io. — Diplocnccus  Gonorrhoea. 

third  or  fourth  day;  it  is  thin  and  watery  at  first,  but 
soon  becomes  thick  and  purulent. 

The  local  manifestations  are  generally  accompanied 
hy  some  general  symptoms  such  as  slight  fever, 
malaise,  general  aching  pains,  especially  in  the  back, 
•constipation,  &c. 

In  the  female,  in  addition  to  the  urethra,  the  cervix 
and  vagina  may  be  involved. 

The  diagnosis  of  the  disease  is  usually  obvious.  In 
doubtful  cases  a  bacteriological  examination  will  deter- 
mine the  nature  of  the  condition. 

The  treatment  in  the  early  stages  should  be  directed 
towards  rendering  the  urine  less  acid  to  prevent 
further  irritation  of  the  inflamed  urethra.  For  this 
purpose  a  mixture  containing  potassium  bicarb, 
gr.     XX     combined     with     linct.      hyoscyami      iiixxv     is 


SPECIFIC  INFECTIVE  DISEASES  89 

given  three  times  a  day.  Saline  purges  should  be 
given  for  the  constipation.  Alcohol  should  be  for- 
bidden, and  a  light  diet,  including  plenty  of  fluids,  such 
as  milk  or  barley  water,  advised. 

Urethral  injections  are  not,  as  a  rule,  required  in 
the  early  stages.  If  the  discharge  continues,  however, 
they  will  be  necessary.  The  usual  injection  given  is 
zinc  permanganate  gr.  J  ad.  ^i  of  warm  water  about 
five  or  six  times  a  day. 

Another  formula  is  tinct.  catechu  illv  and  zinc 
sulphate  gr.i  -ad.  31  of  water. 

If  allowed  to  progress  untreated,  the  inflammation 
which  commences  in  the  anterior  portion  of  the  urethra 
tends  to  spread  back  and  involve  the  posterior  urethra. 
The  disease  then  is  far  more  difficult  to  deal  with,  and 
often  goes  on  to  a  chronic  gleet.  Further  spread  of 
the  disease  may  involve  neighbouring  structures,  the 
most  important  being  the  prostate,  vesiculae  seminales, 
bladder,  or  epididymis.  Treatment  of  the  chronic  con- 
dition is  very  tedious,  involving  a  long  course  of 
urethral  injections. 

Inflammation  of  joints  is  a  frequent  complication  of 
gonorrhoea;  the  knee-joint  is  perhaps  most  frequently 
affected.  An  acute  painful  inflammation  of  a  single 
joint  in  a  young  man,  without  a  history  of  injury,  is 
almost  always  gonorrhoeal  in  origin. 

Gonorrhoeal  conjunctivitis  is  an  important  and  very 
serious  condition,  and  is  dealt  with  in  Chapter  XXIX. 

Perhaps  the  most  frequent  and  one  of  the  most  tire- 
some complications  of  gonorrhoea,  especially  of 
chronic  cases  and  where  the  posterior  urethra  is 
affected,  is  stricUtre.  This  may  show  itself  a  consider- 
able time  after  the  apparent  cure  of  the  disease.  Space 
forbids  us  to  deal  at  any  length  with  the  treatment  of 
stricture.  Dilatation  with  bougies  of  gradually  in- 
creasing size  will  usually  be  successful  in  maintaining 
sufficient  passage  for  the  urine.  In  more  obstinate 
cases  operative  interference  and  cutting-  of  the  stricture 
may  be  required. 

An  antigonococcic  serum  is  now  prepared,  and  in 
some  cases  great  benefits  have  followed  its  use. 

Soft  Chancre  (Ulcus  Molle). —  This  condition  is  only 
of  importance  in  view  of  its  resemblance  to  the  true 
syphilitic  or  hard  chancre.     The  cause  of  the  condition 


90  SURGERY    FOR    DENTAL    STUDENTS 

is  a  streptobacillns  described  by  and  named  after 
Ducrey. 

Ducrcy's  bacillus  (fig.  ii)  is  a  slender,  rod-shaped 
organism;  it  is  very  short,  the  average  length  being 
about  1.5  /A  ;  it  tends  to  form  chains.  No  spores 
are  formed  by  this  organism.  It  stains  moderately 
well  with  simple  stains,  but  not  by  Grain's  method. 
It  is  difficult  to  grow;  blood-agar  is  the  best  medium. 

The  incubation  period  is  from  one  to  five  days.  It 
occurs  almost  invariably  after  coitus,  and  either  sex 
may  be  affected;  extragenital  soft  chancres  are  ex- 
tremely rare. 

A  red  papule  first  appears,  which  becomes  a  vesicle 


Fio.  II. — Ducrey's  Bacillus. 

about  the  third  day,  and  a  pustule  soon  after.  This 
bursts,  leaving  an  extremely  painful  ulcer  with  clean- 
cut  edges,  and  normally  no  induration  of  its  base; 
there  is  considerable  purulent  discharge.  The  ulcers 
are  frequently  multiple,  infection  occurring  from  one 
to  the  other  in  the  same  individual.  This  is  never  the 
case  in  syphilis.  If  the  ulcer  becomes  infected,  the 
base  may  show  some  induration. 

There  is  usually  some  glandular  swelling  in  the 
groins,  sometimes  followed  by  suppuration. 

In  making  the  diagnosis  from  syphilis,  the  following* 
table  may  be  of  value  :  — 

Hard  Chancre.  .Soft   Chancre. 

Incubation     Long,  average  three   weeks,  Short,    one     to    five    days, 

period.              single.  often  multiple. 

Much    induration     of    l^ase.  No     induration    as    a    rule,. 

usually  painless.  painful. 

Secondary  symptoms  occur.  No  secondary  symptoms. 

Spirochcete  found  in  scraping.  Ducrey's  B.  found  in  scrap- 
ing. 


SPECIFIC  INFECTIVE  DISEASES  QI 

Treatment. — The  soft  chancre  usually  heals  in  three 
weeks  under  ordinary  antiseptic  treatment.  The  ulcer 
should  be  washed  with  hydrogen  peroxide  solution, 
dusted  with  iodoform,  and  kept  protected  from  irrita- 
tion. Glands  in  the  groin  should  be  fomented.  If 
they  suppurate  they  should  be  opened  and  scraped, 
plugged  with  iodoform  gauze  and  dressed.  The  in- 
cision should  be  vertical  to  give  free  exit  for  the  pus. 

Syphilis. 

This  and  the  two  following  conditions — viz.,  Tuber- 
culosis and  Actinomycosis — are  known  as  Infective 
granulomata.  This  term  implies  that  the  three 
diseases,  all  due  to  infection  by  specific  organisms, 
are   characterized    by    the    formation    of  inflammatory 


Fig.  12. — Spirochoete  pallida. 

granulation  tissue,  due  to  the  chronic  irritation  which 
occurs  in  all  three  conditions. 

Syphilis  may  be  congenital  or  acquired.  In  both 
cases  it  is  the  direct  result  of  infection  by  the  Spiro- 
chsota  pallida.  This  organism  is  considered  by  most 
authorities  to  be  not  a  bacterium,  but  a  protozoon.  It 
is  spiral  m  shape,  with  about  six  to  eight  curves; 
its  length  is  about  7  /x.  It  possesses  a  flagellum 
at  each  pole,  and  is  motile.  Up  till  quite  recently  it 
had  never  been  obtained  in  pure  culture  outside  the 
body.  Recent  experiments  with  special  media  appear 
to  have  been  successful.  In  order  to  demonstrate  the 
organism,  it  should  be  stained  by  Giemsa's  method. 
This  stains  the  spirochsete  red. 

Numerous  other  spirochsetes  have  been  described 
which   resemble  the    organism    of   syphilis   in   varying 


92  SURGERY    FOR    DENTAL    STUDENTS 

degrees.     Special  methods  are  required  to  distinguish 
them. 

Acquired  Syphilis  usually  follows  coitus,  the  site  of 
inoculation  then  being  the  external  genitals.  Extra- 
genital inoculation  sometimes  occurs,  e.g.,  on  the  lip 
from  an  infected  spoon  or  fork,  or  from  kissing,  &c. 

Three  stages  are  described,  vis.,  Primary,  secondary, 
and  tertiary. 

The  Primary  stage  begins  after  an  incubation  period 
of  from  ten  days  to  six  weeks  (usually  three  weeks)  in 
a  small,  hard,  purplish  nodule.  Occasionally,  if  the 
nodule  be  not  irritated,  it  may  escape  ulceration.  More 
commonly  ulceration  takes  place,  forming  the  Hun- 
terian  or  hard  chancre.  This  is  ^a  circular,  flattened, 
unhealthy-looking-  ulcer  with  an  extremely  hard,  in- 
durated base;  the  discharge  is  thin  and  watery;  the 
ulcer  is  usually  painless. 

Extragenital  chancres  are  very  similar,  but  there  is 
often  considerable  discharge,  and  the  induration  of  the 
base  may  be  less  distinct.  Cases  are  met  with, 
especially  in  extragenital  lesions,  when  the  primary 
lesion  is  so  slight  that  it  escapes  notice  altogether. 

The  glands  in  the  groin  become  enlarged  and  hard. 
They  are  freely  movable  and  painless,  and  rarely  sup- 
purate unless  sepsis  occurs  at  the  site  of  the  chancre, 
when  suppuration  may  occur.  They  are  known  as 
bullet  buboes. 

Hard  chancres  are  almost  invariably  single.  Cases 
in  which  two  lesions  have  occurred  have  been  de- 
scribed. Infection  in  these  cases  attacked  the  two 
places  at  the  same  time;  one  lesion  is  not  inoculated 
from  the  other. 

The  Secondary  stage  is  the  manifestation  of  the 
syphilitic  virus  in  the  general  circulation;  it  usually 
begins  about  six  weeks  after  the  appearance  of  the 
primary  sore ;  it  may  last  any  time  from  a  few  months 
to  two  or  three  years  if  untreated.  The  symptoms 
vary  much  in  severity.  The  onset  is  often  accom- 
panied by  slight  fever,  headache  and  malaise. 

Skin  eruptions  of  various  kinds  occur  in  this  stage. 
The  earliest  to  appear  is  usually  a  macular  rash,  rather 
resembling  that  of  measles.  This  soon  fades,  but 
leaves  behind  it  a  coppery  stain;  sometimes  it  des- 
quamates.      Papular,  vesicular,  pustular,  and  bullous 


SPECIFIC  INFECTIVE  DISEASES  93 

eruptions  may  occur,  two  or  more  different  types  com- 
monly being  present  at  the  same  time.  The  bullous 
eruption  is  known  as  Pemphigus.  The  pustular  rash 
often  dries  up  leaving  scabs,  which,  when  they  dis- 
appear, do  not  show  ulceration  beneath.  This  condi- 
tion is  called  Ecthyma.  Rupia  is  a  condition  in  which 
ulceration  occurs  beneath  a  scab,  causing  the  formation 
of  progressively  larger  scabs,  one  beneath  the  other. 
Any  of  these  eruptions  may  leave  a  coppery  stain  on 
the  skin. 

Condylom^ata  occur  in  positions  where  the  skin  is 
moist,  especially  where  two  skin  surfaces  are  in  con- 
tact, e.g.,  anus,  vulva,  scrotum,  &c.  They  are  slightly 
raised,  well-defined  papules,  with  flat  surfaces  covered 
with  sodden  epidermis,  giving  them  a  whitish  appear- 
ance.    They  are  extremely  contagious. 

Mucous  patches  (mucous  tubercles)  are  similar, 
slightly  raised,  flat,  whitish  patches,  occurring  on 
mucous  membranes,  notably  on  the  cheeks,  palate, 
and  fauces. 

Numerous  other  organs  are  affected  during  the 
secondary  stage. 

The  hair  becomes  dry  and  tends  to  fall  out.  Ulcera- 
tion under  the  nails,  with  swelling  of  the  finger-tip, 
may  occur  {syphilitic  onychia). 

Inflammation  of  the  tongue,  lips,  tonsils,  and  larynx 
is  very  frequent;  it  may  progress  to  ulceration.  It  is 
to  this  laryngeal  inflammation  that  the  hoarseness,  a 
frequent  secondary  symptom,  is  due. 

Lymphatic  glands  are  often  enlarged  and  slightly 
tender,  especially  those  in  the  posterior  triangle  of  the 
neck,  and  above  the  internal  condyle  of  the  humerus. 

Painless  effusion  of  fluid  into  joints  sometimes 
occurs,  the  knee-joint  being  most  commonly  affected. 

Bones  (sec  Chapter  XVII). 

Eye  (see  Chapter  XXIX). 

Orchitis  occurs  as  an  occasional  late  complication. 
The  testis  itself  is  affected,  the  epididymis  and  sper- 
matic cord  commonly  escaping.  The  testis  is  enlarged, 
smooth,  heavy,  firm,  and  painless.  Testicular  sensa- 
tion may  be  lost.     Hydrocele  also  may  be  present. 

The  Tertiary  stage  is  very  variable  in  its  time  of 
onset.  It  may  occur  within  a  few  months  of  the 
primary  lesion,   or  it  may  be  delayed  for  many  years. 


94  SURGERY    FOR    DENTAL    STUDENTS 

It   is   often    overlapped  by   the   later  secondary   mani- 
festations. 

The  typical  tertiary  syphilitic  lesion  is  known  as  a 
Gumma.  This  term  is  used  somewhat  differently  by 
different  writers.  Some  apply  it  to  any  tertiary 
syphilitic  swelling"  or  ulceration,  others  confine  its  use 
to  well-defined  circular  swellings,  the  other  tertiary 
manifestations  being  called  Gmnmatous. 

A  gumma  may  involve  any  organ  in  the  body.  It 
is  accompanied  by  obliterative  endarteritis,  which,  by 
cutting  off  the  blood  supply,  results  in  degenerative 
changes  in  the  gumma. 

On  microscopical  examination  three  zones  are  seen. 
In  the  centre  is  a  mass  of  degenerated  caseous  and 
fatty  material.  Around  this  is  a  ring  of  fibrous  tissue, 
surrounded  in  its  turn  by  an  area  of  round-celled 
infiltration. 

Giant  cells  are  frequently  present.  They  are  smaller 
and  not  so  numerous  as  in  tubercle  (q.v.)  The  proto- 
plasm is  granular;  there  are  few  nuclei  (two  or  threej, 
which  have  no  definite  arrangement  in  the  cell. 

If  a  gumma  involves  the  surface,  ulceration  occurs. 
Gummatous  ulceration  presents  itself  in  various  posi- 
tions, notably  the  skin,  tongue,  epiglottis,  larynx,  &c. 
It  is  very  destructive  in  character.  The  alimentary 
system  may  be  affected  at  either  end,  z'is.,  the  mouth 
or  rectum,  but  rarely  in  other  parts. 

The  tertiary  manifestations  in  various  organs,  such 
as  bones  and  joints,  arteries,  testis,  liver,  spleen,  eyes, 
&c.,  will  be  dealt  with  when  the  diseases  of  these 
organs  are  discussed.  Certain  very  late  manifestations 
of  syphilis,  in  which  the  central  nervous  system  is 
affected,  are  called  parasyphilitic  affections.  Tabes 
dors  alts  and  general  paralysis  are  the  best-known 
examples.  A  text-book  on  medicine  must  be  con- 
sulted for  information  with  regard  to  these  conditions. 

Treatment. — The  treatment  of  syphilis  is  local  and 
general,  the  latter  being  by  far  the  most  important. 

Local  Treatment. — The  primary  sore  should  be 
washed  with  hydrogen  peroxide  solution,  or  Lotio 
hydrargyri  nigra  fblackwash),  and  then  dusted  with 
iodoform  or  dressed  with  calomel  ointment — irritation 
must  be  avoided  as  far  as  possible. 

Secondary  lesions  are  best  treated  with  ammoniated 


SPECIFIC  INFECTIVE  DISEASES  95 

mercury  ointment  (half  the  strength  of  the  B.P.  pre- 
paration). 

Cojidylojuafa  may  be  dusted  with  a  powder  con- 
sisting" of  equal  parts  of  calomel  and  zinc  oxide. 

For  the  throat,  a  gargle  composed  of  liq.  sodae 
chlorinatae  5ss  ad.  3i  is  useful. 

GiDiunata  should  rarely  be  incised.  When  ulcerated, 
they  should  be  treated  on  general  lines  {vide  Ulcera- 
tion). The  half-strength  ammoniated  mercury  oint- 
ment may  be  used. 

General  Treatment. —  In  the  primary  and  secondary 
stages  attention  must  be  paid  to  the  general  health. 
Fresh  air  and  regular  habits  are  important;  alcohol 
should  be  forbidden;  tobacco  is  often  very  irritating 
to  the  throat,  and  should  not  be  freely  indulged  in. 
The  bowels  should  be  kept  acting  regularly,  and  if 
anaemia  is  present,  iron  should  be  given. 

Mercury  has  a  specific  action  upon  the  first  two 
stages  of  the  malady;  it  may  be  administered  in 
various  w^ays. 

(i)  By  the  Mouth. — Hydrarg.  c.  cret.  gr.  i  three 
times  a  day,  the  dose  being  gradually  increased,  or 
liq.  hydrarg.  perchlor.  5i  three  times  a  day. 

(2)  By  Inunction. — Mercury  ointment  is  used. 
5SS  to  5i  should  be  rubbed  in  every  night,  the  area 
used  being  carefully  washed  the  next  morning  to 
avoid  irritation.  A  different  place  should  be  chosen 
each  day,  the  groins  and  axillae  being  most  suitable. 

(3)  ^y  ^^^  Intra-miiscular  Injection. — This  method 
causes  considerable  pain  and  irritation,  and  does  not 
appear  to  possess  any  great  advantages.  Various 
salts  are  used,  the  perchloride  being  perhaps  the  most 
usual.     Metallic  mercury  is  also  used. 

The  mercurial  treatment  of  syphilis  must  be  con- 
tinued for  at  least  two  years,  though  it  need  not  be 
so  freely  administered  during  the  later  stage  of  the 
period.  The  effects  of  the  drug  vary  considerably  in 
different  patients,  some  reacting  quickly  to  very  small 
doses.  A  careful  watch  must  be  kept  upon  the  con- 
dition of  the  mouth  and  gums.  Mouth-washes,  such 
as  chlorate  of  potash  gr.  xv  ad.  3i  should  be  fre- 
quently used;  and  at  the  first  signs  of  soreness  of  the 
gums,  or  salivation  {see  Mercurial  Stomatitis,  p.  i68), 
the   dose   should   be  reduced   until   the  symptoms   dis- 


96  SURGERY    FOR    DENTAL    STUDENTS 

appear.     It  may  even  be  necessary  to  discontinue  the 
drug  altogether  for  a  time. 

Iodides  do  not  appear  to  have  any  beneficial  effect 
upon  the  primary  or  earlier  secondary  stages.  They 
are  sometimes  of  value  in  the  later  stages  of  the 
secondary  period.  Upon  the  tertiary  lesions,  iodides 
have  a  specific  action.  They  should  be  administered 
in  doses  of  10  gr.  three  times  a  day,  at  the  commence- 
ment; the  dose  may  be  increased  later.  If  the  patient 
has  not  undergone  a  two-years'  course  of  mercurial 
treatment  in  the  earlier  stages,  it  may  be  useful  to 
give  mercury  in  combination  with  the  iodide.  A 
useful  prescription  is  :  — 

B     Pot.  iod.  gr.x 

Liq.  hydrarg.  perchlor.  ...  ...  5i 

Tinct.  zingib.    ...  ...  ...  ...  5i 

Decoct,  sarsae  co.  ad.  ...  ...  ...  5^ 

Ji.  three  times  a  day. 

It  is  necessary  when  administering  iodides  to  be  on 
the  look-out  for  any  signs  of  toxic  symptoms  due 
to  the  drug.  lodism,  as  it  is  called,  may  shew  itself 
in  very  varying  forms.  Most  commonly,  symptoms 
of  catarrh  appear,  affecting  the  nasal  and  buccal 
mucous  membranes;  running  from  the  nose,  cough 
with  much  phlegm,  frontal  headache  (from  implication 
of  the  frontal  sinuses),  &c.,  being  present. 

This  may  be  treated  either  by  stopping  the  drug 
temporarily,  or  by  halving  the  dose;  if  the  dose  be 
doubled,  the  symptoms  often  disappear. 

Recent  extensive  researches  by  Ehrlich  have  shown 
that  an  organic  arsenic  compound,  dioxydiamino- 
arsenobenzol,  or  "606''  as  it  is  called,  has  a  remark- 
able effect  upon  all  the  stages  of  syphilis,  even 
including  the  parasyphilitic  affections.  It  is  too  early 
yet  to  be  sure  of  the  ultimate  results  of  the  treatment. 
It  is  given  by  injection  either  subcutaneously  or  intra- 
venously. Opinions  still  differ  as  to  the  correct  dose; 
subcutaneously  about  5  gr.  is  commonly  given.  No 
untoward  effects  seem  to  follow  the  use  of  the  drug. 

Congenital  Syphilis  may  be  inherited  either  from 
father  or  mother.  In  the  former  case,  infection  pro- 
bably occurs  from  the  spermatozoon  at  the  moment 
of  fertilization;  in  the  latter  case,  through  the  placental 


SPECIFIC  INFECTIVE  DISEASES  97 

circulation.  It  may  affect  the  foetus  in  ufcro,  and  is 
a  common  cause  of  miscarriage. 

In  other  cases,  the  child  may  appear  healthy  at 
birth,  the  symptoms  developing  a  few  weeks  to  three 
months  later. 

The  principal  clinical  signs  are  :  Catarrh  of  the  nasal 
and  buccal  mucous  membrane,  causing  snuffles; 
this  interferes  with  the  development  of  the  nasal  bones, 
resulting  in  the  depressed  bridge  of  the  nose,  so 
characteristic  of  the  condition;  general  wasting; 
various  types  of  skin  eruptions,  especially  affecting 
the  buttocks;  condylomata,  mucous  patches,  ulcera- 
tions in  various  parts;  scars  at  the  corners  of  the 
mouth  are  often  left  as  a  memento  of  the  disease. 

G astro-intestinal  symptoms,  such  as  diarrhoea  and 
vomiting,  are  common;  there  is  often  great  swelling 
of  the  abdomen.  Simxilar  affections  of  the  hair,  nails, 
hones,  &c.,  occur  as  in  the  acquired  variety.  Effusions 
into  joints,  especially  the  knee-joint,  are  more  common 
in  the  congenital  than  the  acquired  form ;  the  effusions 
are  often  bilateral.  Later  on,  tertiary  manifestations, 
gummata,  and  gummatous  ulcerations  of  palate,  &c., 
may  appear.     The  skull  is  often  affected. 

Interstitial  Keratitis,  see  Chapter  XXIX. 

The  teeth  are  frequently  affected  in  congenital 
syphilis,  a  deformity  of  the  tooth  occurring  in  some 
cases,  as  well  as  imperfect  calcification.  The  upper 
centrals  are  the  miost  often  affected,  but  all  the  incisors, 
the  canines  and  first  molars  in  the  upper  and  lower 
jaws  may  also  be  deformed.  In  the  incisors  the 
central  denticle  is  deficient  and  the  side  ones  curve 
inwards,  leaving  a  notch  betw^een  them,  so  that  the 
tooth  is  barrel-shaped,  and  notched;  the  canines  also 
shew  a  notch  at  the  apex,  and  the  molars  have  very 
low,  rounded  cusps.  The  enamel  and  dentine  of  such 
teeth  are  imperfectly  calcified.  Typical  syphilitic  or 
Hutchinsonian  teeth  may  very  rarely  be  caused  by  some 
other  lesion  than  syphilis.  A  detailed  description  of 
the  condition  will  be  found  in  Colyer's  "  Dental 
Surgery." 

Tuberculosis. 

Tuberculosis  is  an  infective  granuloma,  due  to  the 
Bacillus   tuberculosis,   a  non-motile,   slender  rod   from 

7 


98  SURGERY    FOR    DENTAL    STUDENTS 

3  to  S  fi  in  length.  It  sometimes  appears  to  branch, 
suggesting  a  relationship  to  the  streptothrices 
(z'idc  Actinomycosis,  p.  lOo).  It  stains  slowly  with 
simple  stains,  and  often  irregularly,  giving  it  a  beaded 
appearance,  and  suggesting  the  presence  of  spores. 
In  all  probability,  however,  the  organism  does  not 
torm  spores.  It  stains  by  Gram's  method.  When 
stained  wath  hot  carbol  fuchsin,  the  stain  is  not  re- 
moved by  dilute  sulphuric  acid,  nor  by  alcohol.  The 
organism  is  therefore  said  to  be  acid-fast  and  alcohol- 
fast.  This  serves  as  a  method  of  differentiating  it 
from  organisms  otherwise  resembling  it.  There  are 
a  large  number  of  acid-fast  organisms,  of  which  the 
most  important  are  the  leprosy  bacillus  and  the 
smegma  bacillus.  (The  latter,  though  acid-fast,  is  not 
alcohol-fast.)       The    B.    leprx    may   be    distinguished 


Fig.  13. — Bacillus  tuberculosis. 

from  the  tubercle  bacillus  by  the  fact  that,  though 
it  will  retain  its  stain  under  weak  acid  {e.g.,  5  per 
cent.  H2SO4),  stronger  acid  will  decolorize  it,  while 
the  tubercle  bacillus  remains  stained. 

The  tubercle  bacillus  can  be  grown  upon  glycerine 
agar,  but  the  growth  is  slow. 

The  typical  lesion  produced  by  the  organism  consists 
of  a  number  of  similar  areas  known  as  miliary  tubercles 
or  grey  granulations.  In  the  early  stages  these  are 
about  the  size  of  a  pin's  head,  and  gradually  increase 
as  the  disease  progresses,  undergoing  degenerative 
changes  in  the  centre. 

A  miliary  tubercle  is  made  up  of  a  number  of  giant 
cell  systems.  On  microscopical  examination,  each 
giant  cell  system  is  found  to  be  composed  of  three 
zones  of  cells.     In  the  centre  are  one  or  more  large^ 


SPECIFIC  INFECTIVE  DISEASES  99 

branching  hyaline  giant  cells  containing  many  nuclei; 
the  nuclei  are  most  commonly  arranged  regularly 
around  the  periphery  of  the  cell.  Tubercle  bacilli  may 
sometimes  be  seen  inside  the  giant  cells.  Around  the 
giant  cell  is  a  zone  of  smaller  mononuclear  cells;  these 
are  known  as  epithelioid  cells,  though  they  are  really 
endothelial  in  origin.  The  branches  of  the  giant  cell 
pass  in  between  these  cells. 

Outside  these  again  is  a  zone  of  small  round  cells, 
mostly  lymphocytes.  Giant  cells  may  occur  in  any 
very  chronic  irritation,  such  as  syphilis,  actinomycosis, 
leprosy,  &c.  {q.v.). 

Owing  to  the  fact  that  the  blood  supply  is  interfered 
with,  there  is  great  tendency  to  fatty  degeneration  and 
caseation;  this  commences  in  the  centre  of  the  growth, 
a  mass  of  caseous  material  being  formed.  In  some 
cases  this  caseous  material  undergoes  liquefaction,  a 
a  mass  of  caseous  material  being  formed.  In  some 
solidification  and,  more  rarely,  calcification  occur. 
Owing  to  the  chronic  irritation  there  is  always  some 
fibrous  tissue  formation;  this  is  greater  in  amount  in 
very  old-standing  cases.  Infection  may  occur  through 
the  respiratory  or  alimentary  tracts,  and  more  rarely 
through  the  skin. 

Anything  which  depresses  the  general  health,  such 
as  overcrowding",  with  its  attendant  evils,  want  of 
fresh  air,  dirty  surroundings,  &c.,  w411  act  as  a  pre- 
disposing cause. 

Various  organs  may  be  affected.  Infection  may 
reach  the  lungs  or  gut  directly,  or  the  skin  (lupus), 
or  it  may  spread  through  the  lymphatics  to  the 
lymphatic  glands;  or,  again,  via  the  blood-stream  to 
other  organs,  such  as  the  bones,  kidney,  testis,  &c. ;  or 
become  a  generalized  infection.  Secondary  infection 
may  occur,  e.g.,  from  the  lungs  to  the  larynx. 

The  clinical  signs  depend  upon  the  particular  posi- 
tion of  the  lesion.  The  manifestations  of  the  disease 
in  those  organs  which  it  is  necessary  for  us  to  discuss 
will  be  found  in  the  chapters  dealing  with  those  organs. 

General  syniptonis  include  progressive  wasting, 
night  sweats,  irregular  fever,  «&c.  In  the  later  stages, 
amyloid  disease  may  occur. 

General  treatment  involves  fresh  air,  good  food,  and 
such  drugs  as  cod-liver  oil,  phosphate  of  iron,  &c. 

For  local  treatment,  see  appropriate  chapters. 


100  surgery  for  dental  students 

Actinomycosis. 

Actinomycosis  is  an  infective  granuloma  due  to  a 
number  of  allied  organisms  belonging"  to  the  Strcpto- 
thrix  group,  often  classed  together  under  the  name 
Actinomyces  or  Ray  Fungus. 

To  the  naked  eye  they  appear  as  little  round  masses, 
seldom  larger  than  a  pin's  head,  of  a  colour  varying 
from  grey  to  greenish  3^ellow.  They  are  usually  soft, 
\  but    occasionally   contain   calcareous    deposit.     Micro- 

'^^  scopically,  each  of  these  colonies  is  seen  to  be  com- 
posed of  a  tangled  mass  of  branching  filaments, 
arranged  radially  at  the  periphery.  The  terminations 
of  these  radially  arranged  filaments  are  often  swollen 
into  pear-shaped  bodies  or  clubs.  Spores  are  also 
formed  in  certain  segments  of  the  filaments. 


Fig.  14. — Actinomyces. 

The  filaments  stain  by  Gram's  method;  the  clubs  do 
not.  The  organism  grows  slowly  in  ordinary  media. 
Very  slow-growing  tumours,  composed  chiefly  of 
granulation  tissue,  which  later  on  undergoes  central 
degeneration  and  suppuration,  are  characteristic  of  the 
disease.  Giant  cells  are  often  present.  They  are 
smaller  than  those  of  tubercle,  and  their  protoplasm 
is  granular.  They  contain  a  few  large  nuclei,  which 
do  not  shew  any  typical  arrangement. 

The  disease  is  common  in  cattle,  the  organisms 
being  in  all  probability  present  on  barley  and  other 
corn.  In  cattle  it  has  received  various  names,  vi:z., 
-wooden  tongue,  cancer,  osteosarcoma,  &c. 

In  man  it  is  found  in  various  situations,  chiefly 
about  the  mouth  and  face,  infection  probably  occur- 
ing  through  a  diseased  tooth  or  small  abrasion.     When 


SPECIFIC  INFECTIVE  DISEASES  10 1 

inhaled,  the  lungs  may  be  affected,   or  the  organism^ 
when  swallowed,  may  attack  the  intestine. 

More  rarely  the  organisms  reach  the  blood,  bringing 
about  a  condition  resembling  chronic  pyaemia,  actino- 
mycotic abscesses  being  formed  all  over  the  body. 

A  common  starting  point  for  the  disease  is  in  the 
lower  jaw.  A  hard  fibrous  tumour  slowly  forms, 
expanding  the  bone,  and  gradually  spreading  to  the 
skin  of  the  cheek,  and  down  into  the  neck.  Free 
suppuration  occurs  with  the  formation  of  numerous- 
sinuses.  When  the  superior  maxilla  is  attacked,  the 
disease  may  spread  to  the  base  of  the  skull,  and  thence 
to  the  brain.  In  other  positions,  similar  phenomena 
occur.  When  the  gut  is  involved,  the  caecum  is  most 
frequently  attacked ;  this  condition  may  simulate  a  very 
chronic  appendicitis. 

Diagnosis. — The  disease  is  readily  mistaken  for 
tubercle,  syphilis,  or  malignant  disease.  The  absence 
of  glandular  involvement  may  be  suggestive,  but 
microscopical  examination  of  the  pus  is  the  only  cer- 
tain means  of  differentiation. 

Treatment. — When  no  vital  organs  are  involved, 
early  free  excision  of  the  diseased  area  should  be 
practised.  If  this  is  impossible,  free  incisions,  and 
antiseptic  treatment  must  be  resorted  to. 

Large  doses  of  potassium  iodide  {e.g.,  30  gr.)  often 
have  greatly  beneficial  effects. 


CHAPTER    XIII. 
GENERAL    CONSTITUTIONAL    DISEASES. 

Rickets. 

Rachitis,  or  rickets,  is  a  general  disease  dependent 
upon  malnutrition,  and  chiefly  affecting  the  bones. 
It  occurs  in  children,  usually  during  the  first  two  years 
of  life.  The  chief  factors  in  its  causation  are  in- 
suflicient  or  improper  feeding,  especially  any  substitute 
for  maternal  milk. 

Under  certain  circumstances,  the  mother  is  incapable 
of  giving  the  required  nourishment.  In  these  cases 
we  must  rely  upon  artificial  substitutes. 

The  chief  pathological  changes  occur  in  the  bones. 
Opinions  differ  as  to  the  exact  interpretation  of  the 
changes  that  take  place.  Some  hold  that  there  is  no 
increased  absorption  of  bone  from  wdthin,  and  that  the 
matrix  laid  down  is  normal,  the  whole  fault  lying  in 
ifnperfect  calcification  of  this  normal  matrix.  Others, 
though  agreeing  that  calcification  is  imperfect,  are 
of  opinion  that  increased  absorption  from  within  does 
take  place. 

Whatever  the  exact  pathology  of  the  condition  may 
be,  it  results  in  great  softening  of  the  bones,  and 
enlargement  at  the  junction  of  the  epiphysis  and 
diaphysis  of  the  long  bones.  The  long  bones  incline 
to  bend,  especially  the  tibiae  and  femora,  genu  valgum 
(knock-knee)  or  genu  varum  (bow  legs)  resulting. 
The  chest  assumes  a  characteristic  pigeon-breast  shape; 
the  upper  ribs  fall  in,  but  the  lower  ribs  are  kept  in 
place  by  the  pressure  of  the  abdominal  organs;  the 
sternum  is  thus  pushed  forward.  Spinal  curvature 
also  occurs.  At  the  junctions  of  the  ribs  with  their 
cartilages,  hard  nodular  swellings  are  formed.  These 
are  known  as  the  rickety  rosary.  There  is  a  great 
tendency  to  greenstick  fracture.  Craniotabes  is  a 
condition  characterized  by  considerable  thinning  of 
the  bones  of  the  vault  of  the  skull.     The  bones  may 


GENERAL     CONSTITUTIONAL     DISEASES  IO3 

become  as  thin  as  paper  in  some  places.  This  con- 
dition may  occur  in  rickets,  and  also  in  congenital 
syphilis. 

The  child  is  restless,  and  cries  a  good  deal,  owing 
to  tenderness  of  the  bones;  night  sweats  are  frequent. 
The  abdomen  is  much  enlarged,  and  alternate  attacks 
of  diarrhoea  and  constipation  often  occur. 

Tetany  and  convulsions  may  follow,  and  laryngismus 
stridulus  ma)^  complicate  the  condition.  Thrush  is  a 
frequent  complication  of  rickets.  Rickets  may  occur 
in  company  with  tubercle  or  congenital  syphilis,  but 
there  is  no  satisfactory  evidence  of  any  connection 
between  these  conditions. 

Treatment  is  long  and  tedious.  Fresh  air,  good 
food  with  plenty  of  fresh  milk,  are  important.  Cod- 
liver  oil  and  syrupus  ferri  phosphatis  may  be  given. 
The  bowels  must  be  kept  regulated.  Hydrarg.  c.  cret. 
gr.  -J  to  I  is  useful.  The  child  must  not  be  allowed 
to  walk;  to  prevent  this  splints  may  be  applied  to  the 
legs  if  necessary. 

Scurvy. 

Scurvy  is  a  disease  which  depends  upon  the  omission 
of  fresh  vegetables  and  fruit  from  the  diet.  It  is 
uncommon  nowadays,  but  at  one  time  was  very  rife 
in   prisons    and    on   board    ship,    where   men   lived   in  . 

confined  quarters  upon  artificially  preserved  foods.  \j 

The  principal  clinical  sigiis  of  the  malady  are : 
Great  weakness  and  prostration,  breathlessness  on 
exertion,  joint  pains,  and  a  tendency  to  spontaneous 
haemorrhages.  The  gums  are  spongy,  and  readily 
bleed.  Haemorrhages  commonly  occur  into  the 
muscles,  causing  painful  swellings.  Purpuric  erup- 
tions may  be  present,  and  there  is  generally  some 
anaemia. 

If  untreated,  fever  and  inflammatory  complications, 
such  as  pleurisy,  occur.  There  may  be  fatal  internal 
haemorrhages,  e.g.,  into  serous  cavities,  or  solid 
organs,  such  as  the  brain. 

Treatment  is  simple,  and  consists  in  supplying  a 
sufficiency  of  fresh  vegetables  and  fruit.  Lime  juice 
is  useful.     Iron  should  be  given  for  the  anaemia. 

Infantile  Scurvy    (Barlow's    disease)    is    a    similar 


104  SURGERY    FOR    DENTAL    STUDENTS 

condition  affecting  infants.  Haemorrhages  under  the 
periosteum  of  the  long  bones  are  common,  and  this 
condition  may  be  easily  mistaken  for  acute  periostitis. 

HEMOPHILIA. 

Haemophilia  is  an  hereditary  disease,  characterized 
by  great  tendency  to  uncontrollable  haemorrhage. 
This  is  due  to  an  absence  or  diminution  in  the  quantity 
of  fibrin  ferment  present  in  the  blood,  and  a  conse- 
quent lessening  of  the  power  of  clotting. 

The  disease  is  transmitted  by  the  females  of  the 
affected  family,  and  not  by  the  males;  it  is  the  males, 
however,  that  most  frequently  suffer  from  the  malady. 
A  female  member  of  the  family  may  transmit  the 
disease  to  her  children,  even  though  she  herself  shews 
no  symptoms. 

It  is  a  very  dangerous  condition,  quite  trivial  opera- 
tions, such  as  the  extraction  of  a  tooth,  resulting  often 
in  fatal  bleeding. 

Great  internal  haemorrhages  may  occur  into  muscles, 
joints,  bursae,  &c.  The  patellar  bursa  is  frequently 
affected  in  this  way  owing  to  its  liability  to  injury. 
The  coagulation  period  of  the  blood  is  commonly 
much  increased;  it  may  be  as  much  as  sixty  minutes 
instead  of  the  normal  three  or  four.  A  considerable 
leucopenia  (diminution  in  the  number  of  leucocytes  in 
the  blood)  is  often  present,  and  also  some  diminution 
in  the  number  of  red  corpuscles. 

The  prognosis  is  always  grave.  The  patient  must 
exercise  extreme  care  in  avoiding  slight  injuries ;  no 
hard  manual  labour  or  violent  exertion  should  be 
allowed.  P'emale  members  of  an  affected  family, 
though  apparently  healthy  themselves,  should  not 
marry. 

No  operations  should  be  performed,  except  in  cases 
of  extreme  emergency.  When  external  bleeding  occurs, 
it  must  be  treated  on  general  lines  {sec  Chapter 
VI),  by  means  of  styptics,  &c.  Calcium  chloride  may 
be  useful  as  a  local  application.  The  value  of  calcium 
given  internally  has  been  much  discussed.  The  fact 
tliat  the  haemophilic  blood  contains  a  normal  quantity 
of  calcium  suggests  that  no  advantage  would  be 
gained  by  administering  more.     But  experiments  have 


GENERAL     CONSTITUTIONAL     DISEASES  IO5 

shewn  that  a  course  of  calcium  definitely  reduces  the 
coagulation  period  in  certain  cases.  One  of  the 
authors  has  succeeded  in  reducing  his  own  coagulation 
period  from  six  to  under  four  minutes  after  the  use 
of  calcium  lactate  lo  gr.  three  times  a  day  for  five 
days.  Clinically,  the  administration  of  calcium  for 
this  period  preparatory  to  necessary  operation  seems 
to  have  a  beneficial  effect  in  the  slighter  cases  of 
hemophilia  (or  supposed  haemophilia). 

It  has  been  pointed  out  that  the  reason  why  the 
blood  of  a  hsemophilic  fails  to  clot  is  that  it  contains 
insufficient  fibrin  ferment.  If  this  substance  can  be 
supplied,  the  blood  should  clot.  Fibrin  ferment  is 
easily  obtained  (it  is  contained  in  normal  horse  serum), 
and  is  most  useful  in  these  cases. 

Status  Lymphaticus. 

Status  lymphaticus,  or  status  thymicus,  is  a  condition 
about  which  very  little  is  known.  It  is  possibly  a 
congenital  affection,  and  may  accompany  such  diseases 
as  rickets.  The  thymus  gland  is  persistent  and  en- 
larged; there  is  a  general  enlargement  of  all  lymphatic 
glands,  and  an  increase  of  lymphoid  tissue  generally. 
Enlarged  tonsils  and  adenoid  growths  are  frequently 
present. 

In  cases  of  sudden  death  under  general  anaesthetics, 
of  apparently  healthy  children,  this  condition  has  fre- 
quently been  discovered  in  the  post-mortein  room. 
It  is  often  impossible  to  recognize  the  condition  ante 
mortem. 

Treatment. — If  the  disease  is  suspected,  general 
hygienic  treatment,  fresh  air,  &c.,  is  required.  The 
tonsils  and  adenoids  should  be  removed,  without  a 
general  anaesthetic. 


CHAPTER   XIV. 
NEW    GROWTHS— SOLID. 

>^        New  growths  or  neoplasms  may  be  solid  or  cystic. 

)  In  this  chapter,  the  most  important  points  in  regard  to 
solid  neoplasms  will  be  considered.  The  word  tumour 
is  used  in  different  senses,  and  this  fact  if  not  realized 
may  be  very  misleading  to  students.  Sometimes  the 
word  is  used  to  mean  any  abnormal  swelling,  not 
necessarily  a  new  growth;  as,  for  example,  an  abscess 
or  an  inflammatory  swelling  in  a  gland.  Again,  it 
may  be  used  to  denote,  a  solid  swelling  in  contra- 
distinction to  a  cystic  swelling;  that  is  to  say,  one 
may  speak  of  "  tumours  and  cysts  "  as  two  different 
classes  of  neoplasm.  In  other  cases  the  term  tumour 
may  be  used  strictly  to  mean  a  neoplasm,  whether 
solid  or  with  fluid  contents.  A  neoplasm  is  a  growth 
of  new  tissue,  which  is  always,  to  a  certain  extent, 
atypical,  performs  no  physiological  function,  and  does 
not  tend  to  disappear  of  its  own  accord.  It  would  be 
undesirable  in  a  manual  of  the  present  scope  to  attempt 
to  exhaust  this  subject,  the  limits  of  which  are  very 
wide;  but  it  is  necessary  to  draw  attention  to  certain 
fundamental  points. 

Many  classifications  of  tumours  have  been  sug- 
gested, and  these  vary  a  good  deal,  especially  in  regard 
to  the  group  of  tumours  known  as  Endotheliomata. 
Many  pathologists  now  include  in  this  class  several 
varieties  of  neoplasm  which  hitherto  have  found  their 
place  in  one  of  the  other  groups.  A  notable  example 
is  the  Melanotic  Sarcoma,  which  some  authorities  now 
regard  as  an  Endothelioma.  For  the  purpose  of  the 
examination  for  which  this  book  is  mainly  intended, 
it  will  be  sufficient  if  the  student  grasps  and  under- 
stands one  of  the  many  classifications  to  be  found  in 
recent  text-books.  The  classification  adopted  in  the 
following  pages  is  taken  from  Rose  and  Carless's 
"  Surgery." 
Solid  tumours  are  first  divided  into  two  great  classes. 


NEW    GROWTHS — SOLID 


107 


vis.,  Simple  and  Malignant.  It  is  essential  that  the 
reader  should  fully  realise  the  differences  between 
these  two  classes.  In  the  following  table  the  main 
points  are  set  forth  :  — 


Malignant   Tumour. 

(i)  Grows  rapidly  in  most  cases. 

(2)  Though  growth  in  some  cases 
may  appear  to  cease  for  a  time, 
it  always  begins  again. 

(3)  Has  no  definite  limits. 

(4)  Tissue  embryonic  and  markedly 
atypical. 

(5)  Tends  to  infiltrate  surrounding 
tissues. 

(6)  Has  great  tendency  to  recur 
locally. 

(7)  Tends  to  form  secondary 
growths. 

(8)  Has  definite  effect  upon  health, 
known  as  cachexia. 


Simple   Tumour. 

(i)  Grows  slowly. 

(2)  Often  ceases  to  grow  after  a 
time. 

(3)  Has  definite  limits. 

(4)  Usually  very  like  normal  adult 
tissue  on  microscopic  examina- 
tion, 

(5)  Never  infiltrates  surrounding 
tissues. 

(6)  If  completely  removed  does  not 
recur. 

(7)  Does  not  form  secondary 
growths  in  other  parts  of  the 
body. 

(8)  Has  no  eft'ect  upon  the  health, 
except  from  its  size  and  weight, 
or  from  such  an  accident  as 
haemorrhage,  pressure  upon  sur- 
rounding -structures,  or  inter- 
ference with  the  function  of  the 
organ  in  which  it  is  situated. 

At  present  the  etiology  consists  mainly   of  theory. 
There  is,   however,   considerable   evidence  suggesting 
that    chronic    irritation    is    an    important 
factor,  especially  in  regard  to  carcinomata. 

Solid  tumours  are  again  divided  according  to  tissues 
from  which  they  arise  into  four  classes,  of  which  the 
first  two  are  the  most  important:  — 

/  (1)  Simple ,  variously 
I  named,  according 
to  the  tissue  com- 
posing them. 
I  (2)  Malignant.  Sar- 
V       coma. 

(II)  Tumours    Chiefly  f  (1)  S.,.^/.   jP^;^^^ 

Hipitiieliai  j^  ^^^  Malignant.     Carcinoma. 

(III)  Endothelial  Tumours. — Endothelioma. 

(lY)  Tumours  due  to  the  inclusion  of  part  of  another 
embryo. — Teratomata. 


etiological 


(I)  Connective  Tissue  Tumours 


I08  SURGERY    FOR    DENTAL    STUDENTS 

(I)  1.— Simple  Connective  Tissue  Tumours. 

A  Myxoma  is  a  tumour  composed  of  myxomatous 
or  mucoid  tissue,  similar  to  that  found  in  the  umbiHcal 
cord  (Wharton's  jelly).  Pure  myxomata,  as  a  rule, 
involve  mucous  surfaces,  and  are  rare.  A  nasal  polype, 
often  spoken  of  as  a  myxoma,  contains  fibrous  tissue 
also,  and  is  therefore  strictly  a  fibromyxoma.  Myxo- 
mata are  semi-translucent,  rounded  tumours  which 
grow  slowly  and  rarely  attain  any  great  size. 

The  treatment  is  to  remove  the  growth. 

A  Fibroma  is  a  tumour  composed  of  fibrous  tissue. 
Two  clinical  varieties  occur,  hard  and  soft,  the  hard 
fibromata  containing  comparatively  fewer  cells  and 
more  fibres  than  the  soft. 

Hard  fibrofnata  occur  around  the  jaws  and  teeth  as 
fibrous  epulis  (q.v.),  and  also  growing  from  the  basilar 
portion  of  the  occipital  bone  downwards  into  the  naso- 
pharynx (fibrous  polypus  of  the  nasopharynx). 

These  tumours  are  very  hard;  on  section  the  surface 
is  whitish  brown  and  glistening.  Sometimes  they 
undergo  sarcomatous  change.  They  should  be 
removed. 

Soft  fibromata  occur  most  commonly  under  the  skin; 
they  do  not,  as  a  rule,  attain  any  great  size,  and  are 
often  multiple.  If  they  cause  symptoms,  or  show  any 
tendency  to  rapid  growth,  they  should  be  removed. 

Soft  fibromata,  in  which  a  number  of  nerve  fibres 
ramify,  arise  from  the  sheaths  of  cutaneous  nerves. 
These  are  known  as  neuroftbromata,  or  false  neuro- 
mata; these  tumours  are  generally  multiple  and  often 
extremely  painful.  When  pigmentation  of  the  skin  is 
associated  with  the  development  of  multiple  neuro- 
fibromata,  the  condition  is  known  as  Recklinghausen's 
disease.  These  tumours,  if  causing  discomfort,  should 
be  removed. 

The  so-called  fibroids,  which  are  so  common  in  the 
uterus,  are  mixed  tumours  containing  muscular  as  well 
as  fibrous  tissue,  and  are  therefore  called  Fibro- 
myomata. 

A  Lipoma  is  a  tumour  consisting  of  ordinary  cellular 
tissue,  infiltrated  with  fat,  and  separated  into  partitions 
by  fibrous  septa.  These  tumours  are  most  common  in 
tlie  subcutaneous  tissue,  and  are  frequently  multiple. 
They  are  soft,  and  often  appear  to  fluctuate,  and  so  are 


NEW    GROWTHS — SOLID  IO9 

liable  to  be  mistaken  for  a  chronic  abscess.  A  lipoma, 
however,  has  a  typical  lobulated  feel,  difficult  to  de- 
scribe, but  easy  to  recognize  when  once  felt;  also,  the 
fibrous  septa  are  attached  to  the  skin,  so  that  the  skin 
dimples  over  the  tumour  when  it  is  moved.  Lipomata 
may  attain  considerable  size,  and  are  prone  to  undergo 
degeneration,  especially  of  the  calcareous  type.  They 
rarely  become  malignant.  When  a  large  area  of  tissue 
undergoes  fatty  infiltration,  as  is  not  uncommon  in 
middle-aged  men  who  drink  a  g'ood  deal  of  beer,  the 
condition  is  known  as  a  Diffuse  lipoma,  or  Lipomatosis. 
The  cellular  tissue  of  the  neck  is  a  common  situation. 

The  treatment  of  the  ordinary  non-diffuse  form  is 
removal,  especially  if  causing  pain.  In  the  diffuse 
form  this  may  be  very  difficult;  in  such  a  case  an 
attempt  may  be  made  to  deal  with  the  condition  by 
removing  the  predisposing  causes,  i.e.,  cutting-  down 
the  alloAvance  of  beer,  and  advising  plenty  of  exercise 
in  the  fresh  air. 

Myoma. — Pure  myomata,  that  is,  tumours  com- 
posed of  the  muscular  tissue  alone,  are  rare.  As  men- 
tioned above,  fibromyomata  are  of  common  occurrence 
in  the  uterus;  they  also  affect  the  prostate  and  the 
ovary.  They  have  a  great  tendency  to  undergo  degen- 
erative changes,  either  calcareous,  mucoid  or  sarco- 
matous. They  may  also  become  infected  with  septic 
micro-organisms. 

The  treatment  of  uterine  or  ovarian  fibroids  lies 
within  the  province  of  the  gynaecologist,  and  the  pros- 
tatic form,  if  causing  symptoms,  requires  operative 
measures. 

Neuroma. — Pure  neuromata  are  very  rare,  and  need 
not  be  discussed.  (For  false  neuromata  see  above, 
under  Fibroma.) 

Chondroma  and  Osteoma.^ — These  tumours  are  dealt 
with  in  Chapter  XVII. 

Glioma. — This  term  is  applied  to  two  different  types 
of  tumour.  A  true  glioma  is  a  tumour  arising  from 
the  neuroglia  of  the  brain  or  spinal  cord.  It  is  quite 
benign,  though  its  growth  may  be  rapid.  It  often 
causes  serious  symptoms  owing  to  its  position.  The 
clinical  diagnosis  of  a  glioma  from  a  sarcoma  is  ex- 
tremely difficult,  and  can  rarely  be  made  with  certainty 
until  after  removal.     It  may  be  distinguished  from  a 


110  SURGERY    FOR    DENTAL    STUDENTS 

gumma  by  the  history  (though  of  course  a  patient  who 
has  had  syphihs  may  have  a  ghoma)  and  by  the  fact 
that  antisyphihtic  remedies  have  no  effect  upon  it.  The 
treatment  therefore  is  always  removal  v/here  the  situa- 
tion of  the  growth  allows  of  operative  interference. 

The  so-called  "  g"lioma  of  the  retina  "  is  not  really 
a  glioma,  but  a  small,  round-celled  sarcoma  (q.v.). 

An  Angeioma  is  a  tumour  wdiich  consists  chiefly  of 
blood-vessels. 

(i)  A  simple  or  capillary  naevus  may  occur  in  the  skin, 
sometimes  involving  the  subcutaneous  tissues  also.  It 
consists  of  dilated  capillaries.  It  is  not,  as  a  rule,  large 
in  size;  its  colour  is  reddish,  hence  the  term  "port 
wine  stain."  It  is  usually  present  at  birth  (sometimes 
called  birtJi-  or  mother's  mark),  and  it  never  appears 
long  after  birth. 

Treatment. — Small  capillary  angeiomata  do  not  re- 
quire treatment  unless  for  cosmetic  purposes.  They 
may  be  destroyed  by  various  methods  of  cauterization, 
e.g.,  electric  cautery,  carbon  dioxide  snow,  actual 
cautery,  or  by  electrolysis,  i.e.,  the  passage  of  an  elec- 
tric current  through  the  tumour.  If  these  methods 
fail,  excision  may  be  required. 

(2)  A  cavernous  angeioma  (venous  nsevus)  may  in- 
volve the  skin  and  subcutaneous  tissues,  and 'occasion- 
ally the  viscera,  especially  the  liver.  It  consists  of 
much  larger  spaces  full  of  blood,  and  separated  by 
septa.  Clinically,  it  forms  a  soft,  easily  compressible, 
lobulated  tumour  of  a  dusky  red  colour,  which  does 
not  pulsate.  The  blood  may  be  driven  out  by  pressure, 
but  returns  as  soon  as  the  pressure  is  removed.  These 
tumours  should  be  excised  if  possible,  or  else  treated 
by  electrolysis. 

Lymphangeiomata  and  Lymph  adenoma.  —  Sec 
Chapter  X. 

Odontomata. — Sec  Diseases  of  the  Jaws. 

2. — Malignant  Connective  Tissue  Tumours. 

A  Sarcoma  consists  of  cells,  which  may  be  round  or 
spindle-shaped,  and  a  fibrous  stroma  which  envelops 
each  individual  cell,  and  separates  it  from  its  neighbours 
(cf.  Carcinoma).  At  first  the  tumour  may  be  encap- 
suled.  but  the  growth  is  never  limited  for  any  length  of 
time,  infiltration  of  surrounding  tissues  soon  occurring. 
Sarcomata  are  very  vascular,  occasionally  so  much  so 


NEW    GROWTHS — SOLID  111 

that  they  pulsate.  Dissemination  occurs  typically  by 
means  of  the  blood-stream,  small  portions  of  the 
tumour  getting  loose  in  a  vessel  and  passing  round  to 
some  other  part  of  the  body,  where  they  hnd  a  resting- 
place  and  commence  to  form  a  secondary  growth. 
These  small  fragments  are  called  Malignant  emboli. 
Dissemination  via  the  lymphatics  sometimes  occurs,  in 
such  varieties  as  lymphosarcoma  and  melanotic  sar- 
coma. Degenerative  changes,  either  mucoid,  fatty  or 
calcareous,  are  common.  These  tumours  may  be  con- 
genital or  may  arise  in  the  first  few  years  of  life.  Apart 
from  this,  they  are  rare  until  after  the  age  of  forty. 
The  following  varieties  are  recognized :  — 

Round-celled  Sarcoma. — Composed  of  round  cells, 
which  may  be  large  or  small.  The  small,  round-celled 
sarcoma  is  usually  the  most  malignant  of  the  two. 
Lympho sarcomata  (vide  Chapter  X),  if  not  identical, 
are  closely  akin  to  this  variety. 

Spindle-celled  Sarcoma,  in  which  the  cells  are  spindle 
or  oat-shaped.  Again,  they  may  be  small  or  large; 
both  varieties  are  very  malignant.  Clinically,  the  shape 
of  the  cells  cannot  be  diagnosed,  especially  as  many 
tumours  (so-called  mixed-cell  sarcoma)  contain  cells 
of  both  shapes;  nor  would  it  be  of  any  practical  value 
if  it  were  possible  to  make  such  a  diagnosis. 

Alveolar  Sarcoma. —  -The  cells  in  this  variety  lie  in 
masses.  The  stroma  does  not  pass  between  each  in- 
dividual cell.  For  this,  and  many  other  reasons,  many 
pathologists  deny  that  these  tumours  are  sarcomatous, 
some  placing  them  among  the  carcinomata,  others 
among  the  endotheliomata. 

Melanotic  Sarcoma. — A  very  malignant  type  of 
tumour  which  affects  the  skin,  and  the  choroid  coat  of 
the  eye.  It  frequently  commences  in  a  pigmented  mole 
or  wart.  The  striking  feature  of  this  variety  is  the 
presence  in  the  tumour  of  a  black  pigment  known  as 
melanin.  In  the  later  stages  of  the  disease  this  pig- 
ment may  appear  in  the  urine,  giving  rise  to  the  con- 
dition known  as  Melaniiria.  Microscopically,  the 
structure  of  the  tumour  is  very  similar  to  an  alveolar 
sarcoma.  There  is  much  difference  of  opinion  as  to 
whether  this  type  also  should  not  be  classed  among 
endothelial  or  carcinomatous  tumours. 

Myeloid  Sarcoma. —  See  Chapter  XVII. 


112  SURGERY    FOR    DENTAL    STUDENTS 

Treatment. — A  sarcoma,  if  diagnosed  early,  before 
the  formation  of  secondary  growths  or  the  involvement 
of  vital  organs,  should  always  be  removed,  as  this 
offers  the  only  reasonable  hope  of  recovery.  In  cases 
where  operation  is  impossible,  other  methods,  such  as 
X-rays,  radium,  or  Coley's  fluid"^  may  be  of  transitory 
benefit. 

(II)  1.— Simple  Epithelial  Tumours. 

A  Papilloma  is  a  tumour  composed  of  a  core  of 
mesoblastic  tissue  covered  by  a  layer  of  epithelium. 
These  growths  are  classified  according  to  the  type  of 
epithelium  which  covers  them,  i.e.,  squamous,  colum- 
nar, or  transitional.  Beneath  the  epithelial  covering 
there  is  most  commonly  vascular  fibrous  tissue.  The 
common  corns  and  warts  are  of  this  type,  as  also  are 
gonorrhoeal  warts,  condylomata  and  mucous  tubercles. 

An  Adenoma  is  a  tumour  composed  of  tissue  closely 
resembling  gland  tissue.  They  vary  in  hardness 
according  to  the  amount  of  fibrous  tissue  which  is 
present;  where  the  fibrous  tissue  is  present  in  any 
quantity  the  tumour  is  called  a  fibro-adenoma.  Adeno- 
mata are  incapable  of  producing  the  secretion  of  the 
gland  in  which  they  arise.  These  tumours  are  common 
in  the  breast,  prostate,  thyroid,  &c. 

Treatment  depends  upon  the  organ  in  which  they 
grow.  As  a  rule,  they  can  be  readily  removed,  and  do 
not  recur  if  the  removal  is  complete. 

2. — Malignant  Epithelial  Tumours. 

Carcinoma. — These  tumours  arise  from  epithelial 
structures,  but  are,  as  a  rule,  quite  atypical  in  micro- 
scopic appearance.  Masses  of  epithelial  cells  grow 
down,  and  invade  the  underlying  mesoblastic  tissue. 
The  connective  tissue  thus  invaded  undergoes  a  chronic 
inflammation  from  the  irritation  caused;  this  chronic 
inflammation  results  in  the  formation  of  fibro-cicatricial 
tissue,  which  eventually  becomes  the  stroma  of  the 
tumour.  The  stroma,  therefore,  surrounds  the  masses 
of  cells,  but  does  not  pass  in  between  the  individual 
cells  (cf.  Sarcoma).  It  varies  in  amount  in  different 
types  of  tumour. 

Carcinomata  are  very  malignant,   spreading  both  by 

*  A  sterilized  culture  of  Streptococcus  pyogenes  and  Micrococcus  pro- 
digiosus,  which  is  injected  into  the  tissue  of  the  tumour. 


NEW    GROWTHS — SOLID  II3 

direct  extension  and  by  way  of  the  lymphatics,  the 
lymphatic  glands  being  therefore  early  involved. 
Secondary  growths  occur  in  the  viscera  and  other  parts 
of  the  body. 

Carcinomata  are  classified  according  to  the  type  of 
epithelial  cells  present :  — 

(a)  Squamous  Carcinoma  or  Epithelioma. — Like  other 
varieties  of  carcinoma,  this  type  occurs  most  com- 
monly in  elderly  people,  that  is  to  say,  from  forty  years 
and  upwards.  Any  part  of  the  skin  or  mucous  mem- 
brane, where  squamous  epithelium  occurs,  may  be  the 
site  of  an  epithelioma.  Chronic  irritation  appears  to 
be  a  strong  predisposing  cause.  This  type  of  tumour 
is  common  upon  the  lips  and  tongue  {q.v.).. 

Microscopically,  the  tumour  consists  of  masses  of 
irregular,  squamous  epithelial  cells,  embryonic  in  type, 
embedded  in  a  fibrous  stroma.  Cell  nests  occur  in  the 
epithelial  columns.  In  the  centre  of  the  cell  nest  are 
a  few  large  squamous  cells,  surrounded  by  layers  of 
crescentic  cells.  These  cell  nests  only  signify  rapid 
cell  growth;  hence,  though  more  frequent  in  malig- 
nant tumours,  may  be  met  with  in  rapidly  progressing 
innocent  epithelial  growths. 

Clinically,  an  epithelioma  begins  as  a  hard  warty 
growth,  which  rapidly  increases  in  size,  and  as  a  rule 
soon  ulcerates.  The  typical  ulcer  has  an  unhealthy, 
sloughy  base,  with  indurated  and  everted  edges.  The 
neighbouring  lymphatic  glands  are  involved  early;  the 
tumour  soon  involves  underlying  tissues.  As  a  rule 
there  is  no  great  pain.  In  some  cases  the  superficial 
growth  is  more  extensive,  a  large  cauliflower-like  mass 
being  formed.  In  other  cases  the  growth  mav  be  com- 
paratively slow,  with  little  ulceration;  under  these 
circumstances  there  is  a  large  amount  of  fibrous 
stroma. 

(b)  Spheroidal-celled  Carcinoma.— Two  varieties  are 
recognized,  the  hard  scirrhns  and  the  soft  encephaloid 
cancer. 

In  the  scirrhns  cancer  there  is  a  comparatively  large 
amount  of  fibrous  tissue,  while  the  cells  are  less  numer- 
ous. It  is  a  very  hard,  relatively  slow-growing  tumour, 
which  on  section  shows  a  yellowish  white  surface  which 
grates  when  cut  with  a  knife.  The  appearance  of  the 
cut  surface  has  been  compared  to  a  section  of  an  un- 
8 


114  SURGERY    FOR    DENTAL    STUDENTS 

ripe  pear.  Microscopically,  the  cells  present  are  seen 
to  be  spheroidal  in  shape.  Fatty  degeneration  is 
common.  Ulceration  occurs  when  the  growth  reaches 
the  surface. 

Clinically,  the  most  common  situation  is  the  female 
breast.  The  stomach,  prostate,  pancreas  and  skin  may 
also  be  affected.  It  forms  a  very  hard  tumour  fixed 
to  the  skin  and  to  underlying  tissues,  frequently 
ulcerated;  the  neighbouring  lymphatic  glands  are  early 
involved. 

Encephaloid  carcinomata  are  rarer  than  the  scirrhous 
type.  There  is  little  stroma,  the  cellular  elements  pre- 
dominating. The  individual  cells  are  larger.  The 
tumour  is  much  softer  and  grows  more  rapidly;  it  is 
often  very  vascular.  The  breast,  stomach,  kidney 
and  upper  jaw  are  most  commonly  involved.  The 
course  of  the  disease  is  very  rapid,  secondary  growths 
being  formed  early,  hence  the  term  Acuie  cancer 
which  has  been  applied  to  this  variety.  A  type  of 
change  known  as  colloid  degeneration  often  occurs, 
the  epithelial  cells  being  replaced  by  gelatinous 
material. 

(c)  Columnar-celled,  or  Glandular  Cancer,  most  fre- 
quently affects  the  stomach  and  intestines,  especially 
the  rectum.  Microscopically,  it  shews  alveoli  lined 
with  columnar  epithelium,  embedded  in  fibrous  stroma. 
These  alveoli  are  very  irregular  in  shape,  and  the 
stroma  is  rather  loose,  these  two  points  helping  to 
distinguish  the  condition  from  a  simple  adenoma. 

Clinically,  it  is  much  like  the  other  varieties,  the 
rapidity  of  its  growth  depending  upon  the  proportion- 
ate quantity  of  cells  present.  Colloid  degeneration 
may  occur. 

Treatment. — Early  and  complete  extirpation  of  the 
growth,  with  the  neighbouring  Ij^mphatics,  is  the  only 
treatment  from  which  cure  may  be  expected.  The 
difficulty  of  complete  removal,  however,  renders  the 
prognosis  always  grave.  X-rays  may  be  used  In  in- 
operable cases. 

fill)  Endotheliomata. —  As  has  been  foreshadowed 
above,  there  is  considerable  difference  of  opinion  as 
to  what  tumours  should  be  included  in  this  class.  The 
so-called  "  mixed  tumour  "  occurring  in  the  parotid 
gland  is  generally  supposed  to  be  endothelial  In  origin. 


NEW    GROWTHS — SOLID  II5 

as  also  are  certain  rare  growths  found  in  the  meninges 
known  as  Psammomata. 

The  treatment,  as  with  other  malignant  growths,  is 
removal  whenever  possible. 

(lY)  Teratomata  are  complex  tumours  arising  from 
the  inclusion  of  part  of  another  embryo.  They  may 
contain  hair,  teeth,  nails,  nipples,  and  even  muscle  or 
bone. 


CHAPTER   XV. 

CYSTS. 

A  CYST  is  a  closed  cavity  whose  contents  are  either 
fluid  or  semi-soHd.  Some  cysts  are  neoplasms,  others 
are  not. 

Cysts  may  be  classified  as  follows :  — 

(I)  Cysts  of  embryonic  origin. 
^        (II)  Cysts  arising  from  the  distension  of  the  pre- 
existing spaces. 

(Ill)  Cysts  of  new  formation. 

(I)     Cysts  of  Embryonic  Origin. 

(a)  Sequestration  Dermoids. — At  certain  parts  of  the 
body  of  the  developing  embryo  clefts  are  present 
which,  during  development,  close  up.  The  two  boun- 
daries of  the  cleft  are  covered  with  epithelium.  Some- 
times when  these  two  boundaries  coalesce,  and  the  cleft 
is  obliterated,  part  of  their  epithelial  covering  is  caught 
inside  the  cleft,  and  cut  off  from  the  general  epithelial 
covering  of  the  body.  This  little  islet  of  epithelium 
may  give  rise  to  a  cystic  swelling,  lined  with  epithe- 
lium, closely  resembling  skin  or  mucous  membrane. 
These  dermoid  cysts  usually  contain  sebaceous  cheesy 
material,  while  hair  frequently  grows  from  the 
epithelial  lining. 

The  common  positions  possible  for  these  cysts  may 
be  guessed  at  from  a  knowledge  of  embryology.  The 
middle  line  of  the  neck,  the  side  of  the  neck  in  the 
positions  once  occupied  by  the  branchial  clefts,  behind 
the  outer  angle  of  the  orbit,  and  at  the  sutures  of  the 
skull,  are  situations  where  dermoids  frequently  appear. 
They  always  develop  during  the  first  few  years  of  life. 

(b)  Tubulo  Dermoids. — These  are  cysts  developed 
in  connection  with  canals,  present  in  the  embryo,  but 
normally  disappearing  before  birth.  The  thyroglossal 
cysts  in  the  neck,  developed  from  remnants  of  the 
thyroglossal  duct  are  of  this  type. 

Clinically,    both    these  varieties    of    dermoids    form 


CYSTS  117 

firm  cystic  swellings,  not  attached  to  the  skin,  but 
frequently  fixed  to  underlying  tissues  (c/.  sebaceous 
cysts);  they  do  not  give  rise  to  pain.  The  diagnosis 
is  generally  easily  made  from  the  position  and  history 
of  the  tumour. 

Treatment. — Dermoids  are  usually  easily  removable. 
The  whole  lining  membrane  should  be  dissected  away 
if  possible,  in  order  to  prevent  recurrence.  If  this 
is  impossible,  the  actual  cautery  should  be  applied  to 
those  parts  of  the  lining  which  are  left  behind. 

(c)  Odontomes. —  See  Diseases  of  the  Jaws,  p.  190. 

(d)  Cysts  connected  with  rudimentary  sexual  organs, 
such  as  Wolffian  or  Miillerian  ducts. 

(II)  Cysts  due  to  the  Distension  of  Pre-existing 
spaces. —  These  cysts  may  be  due  either  to  the  block- 
ing of  the  duct  of  a  gland  and  consequent  retention  of 
secretion,  or  to  increased  secretion  in  a  cavity  which 
has  no  duct. 

A  Sebaceous  Cyst  is  due  to  the  blocking  of  the  duct 
of  a  sebaceous  gland.  It  is  a  smooth,  round,  cystic 
swelling,  attached  to  the  skin,  but  not  to  underlying 
structures,  which  serves  to  distinguish  it  from  a 
dermoid  cyst  (q.v.).  If  left  untreated,  it  may  attain 
large  size,  or  may  become  infected  and  suppurate. 
It  usually  contains  a  quantity  of  cheesy  material. 

The  diagnosis  from  an  abscess  may  be  extremely 
difficult  before  operation,  especially  if  suppuration  has 
occurred.  It  differs  from  a  lipoma  in  being  firmer, 
and  in  not  possessing  the  characteristic  lobulations, 
and  therefore  not  giving  rise  to  the  surface  dimpling 
on  manipulation. 

Treatment. — The  cyst  should  be  entirely  dissected 
out,  and  the  resulting  wound  treated  on  general  lines, 
as  indicated  in  Chapter  VI  (Wounds). 

A  Mucous  Cyst  is  a  similar  condition  occurring  in 
mucous  membranes,  notably  in  the  mouth.  It  is 
usually  sufficient  to  puncture  the  cyst  aseptically,  and 
let  out  the  fluid  contents. 

Cysts  of  this  type  occur  in  various  organs,  notably 
the  breast,  thyroid  (q.v.),  &c. 

(III)  Cysts  of  New  Formation  are  of  various  kinds. 
(a)  Parasitic  cysts  due  to  the  presence  of  a  parasite. 

The  most  common  variety  is  the  hydatid  cyst^  due  to 
the  presence  of  Taenia  echino coccus. 


Il8  SURGERY    FOR    DENTAL    STUDENTS 

(b)  Cysts  formed  by  the  extravasation  of  blood  or 
serous  fluid  into  the  tissues  (blood  cysts  and  serous 
cysts).  If  any  treatment  is  required,  a  simple  aseptic 
puncture  will  generally  be  sufficient. 

(c)  When  a  foreign  body  is  present  for  any  length 
of  time  in  the  tissues  (e.g.,  a  bullet),  a  cyst  may  form 
around  it.  The  treatment  is  to  remove  the  foreign 
body. 

Cysts  also  form  as  the  result  of  degeneration  in 
solid  tumours.    These  are  called  cysts  of  degeneration. 


CHAPTER    XVI. 
INJURIES    OF    BONE. 

Contusions. — A  bone  may  be  bruised  by  a  blow, 
the  force  of  which  is  not  sufficient  to  fracture  it.  If 
the  skin  is  unbroken,  and  the  patient  otherwise  in  good 
health,  a  simple  periostitis  results,  which  rapidly  heals  ^ 
with  rest  and  the  application  of  evaporating  lotions 
(e.g.,  lot.  plumbi.).  If  the  skin  be  broken,  or  if  the 
patient's  resistance  is  below  the  normal,' suppuration 
may  occur.  These  conditions  are  discussed  in  Chapter 
XVII,  under  Acute  Traumatic  Periostitis. 

Fractures  — Many  terms  are  used  to  describe  the 
various  types  of  fracture,  which  require  some  explana- 
tion. A  simple  fracture  is  one  in  which  the  skin  or 
mucous  membrane  is  not  broken;  when  a  breach  of 
surface  has  occurred  communicating  with  the  fracture, 
it  is  called  Compotmd  (cf.  Dislocations). 

A  multiple  fracture  is  one  in  which  the  bone  is 
broken  in  many  places;  when  a  bone  is  crushed  into 
several  small  fragments  it  is  said  to  have  sustained 
a  comminuted  fracture.  Sometimes  one  fragment  is 
driven  into  the  other,  so  as  to  fix  it;  this  is  known 
as  an  impacted  fracture.  Greenstick  fractures  occur 
in  children,  because  their  bones  are  somewhat  softer 
than  those  of  adults.  The  bone  is  bent  in  a  curve, 
until  the  outer  part  gives  way,  while  the  inner  part 
is  not  fractured,  just  as  a  bit  of  green  wood  may  be 
incompletely  fractured. 

Method  of  Union. —  This  process  does  not  materially 
differ  from  the  description  of  healing  of  wounds, 
except  for  the  fact  that  bone  is  formed  instead  of  scar 
tissue. 

If  the  two  broken  ends  of  the  bone  are  in  apposition, 
and  asepsis  has  been  maintained,  the  process  is  as 
follows :  First,  the  blood-clot  which  invariably  sur- 
rounds fractured  ends  of  bone  is  invaded  and  absorbed 
by  leucocytes,  and  rapidly  replaced  by  granulation 
tissue.     This  is  known  as  the  provisional  callus,  and 


120  SURGERY    FOR    DENTAL    STUDENTS 

consists  of  two  layers,  an  external  layer  formed  by  the 
periosteum,  and  an  internal  layer  formed  in  line  with 
the  medullary  cavity.  The  provisional  callus  becomes 
firmer,  and  begins  to  ossify  during  the  third  week; 
ossification  is  usually  complete  in  about  six  weeks  from 
the  time  of  injury. 

Between  the  two  layers  of  the  provisional  callus  is 
a  space  corresponding,  more  or  less,  to  the  actual 
width  of  the  osseous  tissue  in  the  normal  bone,  as 
it  existed  before  the  fracture;  that  is  to  say,  the  dis- 
tance between  the  periosteum  on  the  outside,  and  the 
outer  border  of  the  medullary  cavity  on  the  inside. 
This  space  now  becomes  filled  up  with  granulation 
tissue,  in  which  ossification  rapidly  takes  place, 
generally  being  completed  about  three  months  from 
the  date  of  the  injury.  This  last  formation  of  bone 
is  known  as  the  definitive  callus,  and  it  is  by  means 
of  this  tissue  that  the  union  ultimately  takes  place. 
As  soon  as  the  definitive  callus  is  completely  ossified, 
absorption  of  the  provisional  callus  commences.  This 
process  of  absorption  may  last  a  year  or  more. 

Sepsis  has  a  similar  effect  'Upon  the  healing  of  a 
fracture  as  it  has  upon  a  wound,  rendering  the  whole 
process  lengthier,  and  the  callus,  though  formed  in 
excessive  quantity,  is  frequently  inferior  in  strength. 

When  the  ends  of  the  fragments  are  not  in  correct 
apposition,  it  will  be  clear  that  union  will  be  delayed, 
as  the  actual  amount  of  callus  required  will  be  greater; 
the  ultimate  shape  of  the  bone  will,  of  course,  be 
faulty. 

Anything  intervening  between  the  two  ends,  such 
as  a  piece  of  torn  periosteum,  will  considerably  delay, 
if  not  entirely  prevent,  union. 

Fractures  are  common  during  the  first  two  or  three 
years  of  life.  From  about  3  years  old  till  7  they 
l3ecome  rarer.  From  7  upwards  they  increase  in  fre- 
quency. In  childhood  and  adult  life  the  male  sex  is 
more  often  affected,  but  in  old  age  the  reverse  is 
the  case. 

Certain  diseases  of  bone  predispose  to  fracture, 
e.g.,  rickets  (q.v.),  osteomalacia,  tumours,  &c. 

The  exciting  cause  of  fracture  is  almost  always 
injury,  either  direct  or  indirect.  In  certain  cases,  a 
bone  may  be  broken  by  muscular  action  alone,  notably 


INJURIES    OF    BONE  121 

the  patella;  while  in  very  severe  disease  of  the  bone, 
the  fracture  may  be  apparently  spontaneous. 

General  Clinical  Signs — 

(i)  History  and  signs  of  local  injury,  e.g.,  pain, 
tenderness,  bruising,  and  if  a  few  hours  have  passed, 
considerable  swelling. 

(2)  Incr-cascd  mobility  of  the  part,  unless  the  fracture 
is  impacted. 

(3)  Deformity  of  the  part,  and  alteration  in  the 
relative  position  of  the  bony  points. 

(4)  Loss  of  power  of  movement  of  the  part. 

(5)  Alteration  in  length  of  the  limb. 

(6)  Crepitus. — A  grating  feeling  which  may  be 
detected  when  the  two  fragments  are  made  to  rub 
against  each  other.  This  sign  cannot,  of  course,  be 
elicited  if  the  fracture  be  impacted. 

(7)  Fever. — Slight  as  a  rule,  unless  the  fracture  be 
compound. 

(8)  Shock,  which  varies  in  severity,  according  to  the 
extent  of  injury  sustained  by  the  soft  parts,  the  amount 
of  haemorrhage,  &c. 

Diagnosis. — In  most  cases  the  presence  of  a  fracture 
is  obvious  at  once.  Difficulty  may  be  experienced 
when  a  dislocation  is  present  with  the  fracture. 
X-rays  should  always  be  employed  to  aid  in  the 
diagnosis  when  possible.  ( 

The  presence  of  a  form  of  crepitus  due  to  some  other 
cause  may  be  puzzling.  There  is  a  form  of  teno- 
synovitis (inflammation  of  the  tendon  sheaths)  which 
often  occurs  in  the  tendons  around  the  wrist  in  washer- 
women. This  is  accompanied  by  swelling  and  soft 
crepitus,  and  may  be  mistaken  for  a  fracture  of  the 
radius,  especially  as  the  patient  often  gives  a  history 
of  some  injury  to  which  she  attributes  the  condition. 
The  absence  of  the  typical  deformity  should  determine 
the  nature  of  the  case.  If  there  is  any  doubt,  the  use 
of  X-rays  will  clear  up  the  matter  at  once. 

Treatment. — No  definite  methods  of  reduction,  such    ^ 
as  are  given  for  the  reduction  of  various  dislocations,     V 
can  be   described;   each   fracture   requires   to   be   dealt 
with  as  the  particular  case  demands.     In  most  cases 
a    combination    of    traction    and  manipulation    of    the 
fragments    is    required.     An    anaesthetic    is    of    great 


122  SURGERY    FOR    DENTAL    STUDENTS 

assistance  in  overcoming  muscular  resistance,  as  well 
as  for  the  relief  of  pain.  In  certain  cases,  especially 
in  very  old  people,  impaction  may  be  the  best  possible 
thing  for  the  patient.  But  in  most  cases  impacted 
fractures  must  be  broken  dow^n,  so  that  the  fragments 
may  be  replaced  in  correct  apposition. 

When  the  correct  position  of  the  fragments  has  been 
attained,  means  must  be  taken  to  ensure  their  remain- 
ing in  this  position  till  union  has  occurred.  Splints 
of  various  kinds  are  used;  v^here  splints  cannot  be 
applied,  as  in  the  case  of  a  fractured  rib,  strapping 
may  be  useful.  Where  no  appliance  of  this  sort  will 
suffice  to  retain  the  fragments  in  position,  operative 
treatment,  e.g.,  wiring  or  screwing  the  fragments 
together,  may  be  required. 

If  the  patient  is  seen  immediately  after  the  injury, 
splints  may  be  applied  at  once  in  the  hope  of  limiting 
the  amount  of  swelling.  If,  however,  swelling  has 
already  commenced,  a  temporary  dressing  must  be 
applied  until  the  swelling  has  subsided. 

Before  applying  a  splint,  the  part  must  be  carefully 
cleaned,  and  dusted  over  with  a  little  boracic  powder 
to  prevent  itching.  Care  must  be  taken  to  pad  the 
splint  thoroughly,  and  to  apply  it  firmly  enough  to 
retain  the  bones  in  position,  but  not  so  tightly  as  to 
impede  the  circulation  or  injure  the  nerves. 

Always  see  your  patient  again  within  twenty-four 
hours  of  applying  the  splint,  to  make  sure  that  no 
pressure  upon  vessels  or  nerves  is  caused  by  the 
apparatus.  If  any  signs  of  pressure  are  present,  the 
whole  apparatus  must  be  removed,  and  reapplied  less 
firmly. 

Massage  and  passive  movement  of  the  part  form  an 
important  part  of. the  treatment.  The  time  at  which 
they  should  be  commenced  naturally  varies  with  the 
})osition  and  extent  of  the  injury,  and  no  rigid  rule 
can  be  laid  down.  As  a  rule,  in  a  simple  uncomplicated 
fracture  in  a  limb,  massage  may  be  begun  on  the  day 
after  the  injury,  and  passive  movements  a  few  days 
later.  The  splint  may  often  be  removed  after  a  fort- 
night, and  in  a  month  the  patient  may  begin  to  use 
the  limb.  It  must  be  fully  understood  that  the  times 
given  above  will  require  adjusting  to  meet  the  require- 
ments of  each  individual  case.     Compound  fractures, 


INJURIES    OF    BONE  1 23 

and  those  in  which  severe  injury  to  the  soft  parts  has 
occurred,  require  operative  interference;  the  question 
of  amputation  must  be  considered  in  very  severe 
injuries. 

Non-union.  — In  some  cases  where  a  fracture  is 
associated  with  severe  disease  of  the  bone,  the  vitahty 
of  the  tissues  may  be  lowered  to  such  an  extent  that 
no  attempt  at  union  is  made.  This  is  also  frequently 
the  case  in  extreme  old  age. 

In    other    cases,  the    fragments    may   be    united    by       ^  ; 
fibrous    tissue,    without  the   formation    of   new   bone.  n1 

This  fibrous  union  commonly  results  if  the  fragments  ^ 

are  put  up  in  a  very  faulty  position. 

When  failure  of  union  occurs,  a  false,  joint  may 
result.  The  ends  of  the  fragments  become  covered 
w^ith  cartilage  or  bone,  and  slightly  altered  in  shape 
so  that  they  may  glide  one  upon  the  other,  a  bursa 
usually  being  formed  between  them. 

Special  Fractures. — In  this  section  the  signs  and 
treatment  of  fractures  of  the  bones  of  the  head  will 
be  briefly  described. 

Skull. —  Fractures  of  the  skull  are  of  importance 
mainly  on  account  of  the  possible  consequences  of 
injury  to  the  brain.  They  are  conveniently  divided 
into  fractures  of  the  base  and  of  the  vault  of  the  skull. 

Fractures  of  the  base  may  be  due  to  direct  or  in- 
direct violence,  and  are  generally  of  the  fissured 
variety.  They  are  almost  invariably  compound,  from 
the  involvement  either  of  the  ear,  the  nose,  or  one 
of  the  air-sinuses.  The  fracture  may  involve  either 
the  anterior,  middle,  or  posterior  fossa  of  the  skull. 
In  the  first  case  blood,  and  sometimes  cerebrospinal 
fluid,  is  discharged  from  the  nose;  extravasation  of 
blood  under  the  conjunctiva  and  in  the  loose  tissue 
around  the  eyelids  occur.  When  the  middle  fossa  is 
affected,  the  haemorrhage  and  discharge  of  cerebro- 
spinal fluid  occurs  from  the  ears.  If  the  fracture 
involves  only  the  posterior  fossa,  the  signs  ;are  less 
pronounced;  extravasation  under  the  scalp  in  the 
occipital  region  may  be  present.  The  site  of  the  lesion 
may  be  further  localized  by  symptoms  dependent  upon 
injury  to  the  brain,  such  as  paralysis  of  limbs,  or  of 
cranial  nerves,  &c. 

Fractures  of  the  vault  are  commonly  due  to  direct 


124  SURGERY    FOR    DENTAL    STUDENTS 

violence;  they  may  be  fissured,  depressed,  or  punc- 
tured. In  slight  cases  no  symptoms  beyond  those  ot 
a  simple  contusion  may  be  present,  in  which  case  the 
fracture  may  easily  remain  unrecognized.  If  cerebral 
symptoms  are  present,  they  will  take  the  form  either 
of  concussion  or  compression  of  the  brain. 

The  symptoms  of  cerebral  concussion  make  their 
appearance  immediately  after  the  injury.  The  patient 
appears  to  be  unconscious,  but  can  be  roused  suffi- 
ciently to  answer  "  Yes  "  or  "  No  "  to  questions,  by 
shouting  in  his  ear.  The  pulse  is  rapid  and  weak. 
The  pupils  readily  react  both  to  light  and  accommoda- 
tion. Faeces  and  urine  may  be  passed  involuntarily. 
As  recovery  commences  vomiting  frequently  occurs. 

Cerebral  compression  is  a  more  grave  condition,  and 
usually  results  from  a  more  violent  injury.  The  onset 
of  symptoms  is  slightly  delayed,  perhaps  for  a  quarter 
of  an  hour.  The  patient  becomes  unconscious,  and 
cannot  be  roused  by  external  stimuli.  The  pulse  is 
slow  and  irregular;  the  pupils  do  not  react  to  light 
or  accommodation.  Retention  of  urine  is  a  frequent 
symptom;  vomiting  does  not  occur. 

Treatment. — Speaking  generally,  if  a  fracture  of  the 
vault  of  the  skull  is  diagnosed,  operative  treatment 
should  be  undertaken  at  once.  In  slight  fissured 
fractures,  where  no  signs  of  compression  are  present, 
it  may  be  permissible,  perhaps,  to  delay  operation  in 
the  hope  of  avoiding  it  altogether.  It  may  then  be 
treated  as  a  contusion,  by  means  of  ice-bags  and  rest. 

Fractures  of  the  base  rarely  admit  of  operation,  and 
are  frequently  fatal.  ''Expectant  treatment" — i.e., 
rest,  the  application  of  cold,  and  the  avoidance  of 
sepsis,  as  far  as  possible — is  all  that  can  be  done. 

Nasal  Bones." — Fracture  of  the  nasal  bones  is  gen- 
erally due  to  direct  violence,  and  frequently  involves 
both  bones  and  also  the  septum  nasi.  There  is  pain 
and  swelling  of  the  part,  while  crepitus  can  often  be 
detected.  Surgical  emphysema  (air  in  the  tissues) 
may  occur.     Severe  epistaxis  is  a  common  symptom. 

Treatment. — In  most  cases,  it  is  a  simple  matter  to 
replace  the  fragments  by  means  of  a  blunt,  padded 
instrument  in  the  nostril  and  a  finger  outside.  If 
the  patient  is  careful,  it  is  often  possible  to  retain 
the  bones  in  position  without  a  splint.     Otherwise,  a 


INJURIES    OF    BONE  I25 

gutta-percha  splint  may  be  applied  outside,  and  the 
nostril  plugged  with  lint.  This  plugging  must  fre- 
quently be  changed,  and  the  nose  washed  out  with 
an  alkaline  lotion.  For  cases  in  which  great  difficulty 
is  experienced  in  retaining  the  fragments  in  position, 
more  complicated  apparatus  has  been  devised,  of  which 
Cobb's  nasal  splint  is  the  best  known.  The  condition 
may  be  complicated  by  fracture  of  the  nasal  process 
of  the  frontal  bone,  the  ethmoid  or  the  lachrymal  bone. 

Lachrymal  Bone. — Fracture  of  this  bone  rarely 
occurs,  except  in  association  with  fracture  of  the  nasal 
and  ethmoid  bones.  The  injury  is  not  of  any  great 
importance  except  in  so  far  as  it  causes  pressure  upon 
the  lachrymal  duct.  An  attempt  should  be  made  to 
replace  the  fragments  by  means  of  a  blunt  instrument 
through  the  nose.  The  nasal  duct  must  be  kept 
patent  by  the  passage  of  a  probe  through  it. 

Malar  Bone. — When  this  bone  is  fractured,  it  is 
generally  a  part  of  an  extensive  injury  in  which  the 
superior  maxilla  and  other  bones  are  involved;  the 
antrum  of  Highmore  is  frequently  injured,  and  this 
latter  complication  renders  the  fracture  compound. 
The  body  of  the  bone  is  most  commonly  injured. 
There  is  considerable  pain,  swelling  and  discoloration, 
and  a  distinct  flattening  of  the  side  of  the  face. 
Crepitus  and  mobility  of  the  fragments  are  signs  which 
can  rarely  be  made  out.  If  the  injury  affects  the 
antrum,  severe  unilateral  epistaxis  may  occur. 

The  zygomatic  arch  may  also  be  broken;  this  is  a 
rarer  injur}^;  there  is  obvious  displacement  of  the  frag- 
ments, which  renders  the  diagnosis  easy. 

Treatment. — An  attempt  should  first  be  made  to 
replace  the  fragments  with  the  help  of  a  finger  inside 
the  mouth.  This  method  does  not  often  meet  Avith 
success.  Operative  measures  will  then  be  required. 
An  incision  is  made  through  the  buccal  mucous 
membrance  in  the  neighbourhood  of  the  canine  fossa, 
the  site  of  the  injury  being  reached  through  the 
antrum,  which  cavity  is  afterwards  packed  with  gauze. 
The  danger  of  sepsis  w^ith  this  method  is  considerable. 
The  fracture  may  also  be  reached  through  an  external 
skin  incision;  the  danger  of  sepsis  is  thus  avoided, 
and  the  operation  rendered  much  easier,  but  a  scar 
will  be  left  in  a  prominent  position  on  the  face. 


r 


126  SURGERY    FOR    DENTAL    STUDENTS 

Superior  Maxilla.  — Fractures  of  the  body  of  this 
bone  follow  direct  violence,  such  as  a  gun-shot  wound 
or  the  kick  of  a  horse.  The  nasal,  ethmoid,  or  malar 
bones  are  often  involved  as  well;  the  fracture  is 
generally  compound. 

The  diagnosis  is  usually  easy  from  the  history  of  the 
injury,  and  the  displacement  and  abnormal  mobility 
of  the  fragments  of  the  bone. 

Slight  fractures  of  the  alveolar  process  accompany 
extraction  of  teeth;  no  treatment  is  required  for  this 
variety. 

Treatment  of  Fractures  of  the  Body. — The  chief 
point  in  the  treatment  of  the  condition  is  cleanliness. 
When  the  fragments  have  been  carefully  replaced  by 
means  of  the  fingers  or  blunt  instruments,  great  care 
must  be  taken  in  washing  out  the  mouth  and  keeping 
it  clean.  If  possible,  the  patient  should  be  fed  by  the 
rectum  for  the  first  few  days  at  least.  In  many  cases 
no  splint  need  be  applied,  the  jaws  being  kept  closed 
by  means  of  a  four-tail  bandage.  If  the  fragments 
cannot  be  kept  in  place  in  this  way,  a  splint  must  be 
used.  Many  types  of  apparatus  have  been  devised,  of 
which  the  Gunning  splint,  and  the  Hammond's  wire 
splint  {see  P>actures  of  Mandible),  are  examples. 
Each  case  will  probably  require  a  special  apparatus; 
the  point  to  be  aimed  at  being  to  retain  the  fragments 
in  place  with  some  apparatus  that  is  readily  kept  clean. 

Mandible. — Fracture  of  the  lower  jaw  is  a  compara- 
tively common  accident,  and  one,  moreover,  which  is 
frequently  referred  to  the  dental  surgeon  for  treat- 
ment. It  will  be  necessary,  therefore,  to  consider  the 
condition  somewhat  in  detail. 

It  most  commonly  occurs  as  the  result  of  direct 
violence,  and  affects  adults  more  often  than  children 
or  the  aged.  The  more  or  less  friendly  encounters 
with  which  the  lower  classes  love  to  wile  away  the 
hours  of  Saturday  night  are  responsible  for  the 
majority  of  these  injuries.  Gun-shot  wounds  may 
also  result  in  such  an  injury. 

Occasionally  the  lower  jaw  may  be  fractured  by 
indirect  violence;  for  instance,  lateral  compression 
from  both  sides  may  result  in  a  fracture  near  the 
symphysis. 

The   body   of  the  bone   is  most   frequently  injured. 


INJURIES     OF    BONE  I27 

A  fracture  may  occur  at  any  point  from  symphysis  to 
angle.  The  most  common  positions  are  in  the  region 
of  the  canine  tooth,  between  the  first  and  second 
molars,  and  behind  the  third  molar;  the  frequency 
being  in  the  order  named. 

The  injury  is  almost  invariably  compound.  The 
amount  of  displacement  varies  considerably  with  the 
situation  of  the  injury  and  the  amount  of  violence 
which  causes  it.  If  the  injury  is  bilateral,  the  displace- 
ment is  much  greater.  The  posterior  fragment  is 
usually  drawn  upwards  by  the  masseter,  temporal  and 
internal  pterygoid  muscles.  In  a  unilateral  fracture 
there  is  often  little  or  no  displacement  of  the  anterior 
fragment,  but  when  the  body  is  broken  on  both  sides 
the  depressors  of  the  jaw  draw  the  anterior  fragment 
downwards. 

The  alveolar  process  frequently  undergoes  slight 
injury  during  the  extraction  of  teeth,  small  portions 
being  torn  away.  No  treatment  is  necessary  (cf. 
Superior  Maxilla). 

The  Ascending  Ramus  may  be  fractured  from  similar 
causes  to  those  described  under  fracture  of  the  body. 
There  is,  as  a  rule,  little  or  no  displacement,  but  the 
swelling  and  bruising  of  the  soft  parts  is  often  con- 
siderable. 

The  diagnosis  of  a  fracture  of  the  jaw  is  usually 
simple;  the  history  of  the  injury  and  the  obvious  dis- 
placement of  the  fragments  being  clear  indications  of 
the  condition. 

Treatment. — The  great  essential  in  the  treatment  of 
a  fracture  of  a  mandible  may  be  summed  up  in  the  one 
word,  cleanliness.  It  is  obvious  that  the  situation  of 
the  lesion  renders  cleanliness  most  difficult  to  obtain, 
especially  if  the  patient  is  fed  by  the  mouth.  The 
patient  is,  of  course,  unable  to  masticate  food,  so  that 
any  nourishment  given  by  the  mouth  must  be  in  liquid 
form;  and  it  is  well-nigh  impossible  to  prevent  the 
food  from  collecting  around  the  teeth  and  the  site  of 
fracture.  Under  these  circumstances,  cleanliness 
cannot  be  satisfactorily  maintained.  It  is  wise,  there- 
fore, for  the  first  few  days  at  least,  to  suspend  mouth 
feeding  altogether,  and  to  feed  the  patient  by  the 
rectum.  IT  this  is  done,  and  the  mouth  frequently 
washed  with  hydrogen  dioxide  lotion,  rapid  healing 
mav  be  induced. 


128  SURGERY    FOR    DENTAL    STUDENTS 

The  teeth  should  be  carefully  scaled,  and  all  septic 
teeth  extracted. 

The  displacement  is  usually  easy  to  reduce,  but  it  is 
by  no  means  easy  to  retain  the  fragments  in  a  correct 
position.  Some  form  of  appliance  to  fix  them  will, 
therefore,  be  required.  A  few  cases,  where  there  is 
little  or  no  displacement,  have  been  successfully  treated 
by  the  application  of  a  four-tail  bandage  alone,  but 
these  cases  are  uncommon.  In  the  great  majority  of 
these  injuries  an  internal  splint  will  be  required,  and 
for  the  successful  adaptation  of  such  a  splint  an 
impression  is  necessary.  The  operation  of  taking  a 
correct  impression  without  causing  considerable  pain 
to  the  patient  necessitates  very  delicate  manipulation, 
which  cannot  be  learnt  from  a  book.  Students  should 
take  every  opportunity  of  seeing  this  operation  actually 
performed;  and  in  hospital  practice  these  opportunities 
are  not  rare.  Soft  wax  is  the  material  usually  chosen 
in  that  it  does  not  tend  to  push  the  fragments  out 
of  place,  and  that  absolute  accuracy  is  not  an  essential. 

Many  varieties  of  splint  have  been  devised,  and 
widely  different  opinions  are  expressed  as  to  the 
relative  value  of  these  appliances.  The  Tomes's 
Splint,  which  consists  of  a  metal  cap,  struck  up  to  a 
zinc  to  cover  the  tops  of  the  teeth,  and  fixed  to  them 
with  osteo,  makes,  as  a  rule,  a  very  satisfactory 
appliance. 

Hammond's  Wire  Splint  consists  of  soft  iron  wire 
bent  up  to  fit  both  lingual  and  labial  surfaces  of  the 
teeth.  The  displacement  having  been  corrected,  the 
splint  is  placed  in  position,  and  fixed  to  the  teeth  by 
means  of  binding-wire. 

The  Gunning  Splint  is  an  apparatus  composed  of 
vulcanite,  which  covers  both  the  upper  and  lower  teeth, 
a  four-tail  bandage  being  subsequently  applied.  Av 
important  disadvantage  under  which  this  splint 
labours  is  the  difficulty  of  keeping  the  mouth  clean. 
It  may  be  useful  when  both  jaws  are  fractured. 

The  Cradle  Splint,  suggested  by  Lewin  Payne,  con- 
sists practically  of  two  Hammond's  splints,  one  for 
the  lower  and  one  for  the  upper  law.  The  two  splints 
are  connected  by  upright  wires,  both  on  the  labial  and 
lingual  aspects  of  the  teeth.  Silver  wire  is  commonlv 
employed   in    making    this    splint.      This    Is    a    much 


INJURIES     OF    BONE  12C} 

cleaner  apparatus  than  the  Gunning  spHnt,  and  seems 
to  be  equally  efficient  in  keeping  the  fragments  in 
position.  It  is  especially  useful  in  cases  where  the 
fracture  is  far  back,  and  may  be  adapted  to  fracture 
of  the  upper  as  well  as  the  lower  jaw. 

If  an  external  wound  is  present,  it  must  be  treated 
on  general  lines, "  that  is  to  say,  washed  out  with 
hydrogen  peroxide,  and  dressed  aseptically.  In  most 
cases  the  splint  must  be  kept  in  position  for  six  or 
eight  weeks. 

If  the  site  of  the  fracture  is  far  back  on  the  body, 
or  on  the  ascending  ramus,  the  diagnosis  is  more 
difficult,  and  the  displacement  cannot  be  easily  cor- 
rected by  means  of  splints.  The  use  of  X-rays  in 
determining  the  seat  and  character  of  the  lesion  is 
here  of  great  value.  The  only  splint  which  is  likely 
to  be  useful  in  these  cases  is  the  cradle  splint. 

In  most  cases  of  a  fracture  far  iback,  however,  it 
will  be  necessary  to  expose  the  bone  by  operation, 
and  wire  the  fragments  together.  The  danger  of 
sepsis  is  considerable. 

Hyoid  Bone. — Fracture  of  the  hyoid  bone  is  not 
common.  It  results  from  direct  violence,  such  as 
strangling  or  hanging.  The  signs  of  the  injury  are 
characteristic,  vis.  :  — 

(a)  Great  pain  on  moving  the  tongue,  neck,  or 
lower  jaw. 

(b)  Swallowing  is  almost  impossible. 

(c)  Marked  dyspnoea,  accompanied  by  a  hoarse, 
metallic  cough. 

(d)  Swelling  and  bruising  over  the  position  of  the 
hyoid  bone. 

Treatment. — The  fracture  should  be  reduced  by 
manipulation,  one  finger  being  placed  in  the  mouth, 
and  the  other  hand  outside  on  the  front  of  the  neck. 
A  moulded  splint  of  poroplastic  material  may  be 
applied,  like  a  collar;  but  in  most  cases,  if  the  patient 
be  kept  absolutely  quiet,  fed  by  the  rectum,  and  for- 
bidden to  talk,  or  move  the  tongue,  neck,  or  mandible, 
no  splint  will  be  required. 


CHAPTER    XVTl. 
DISEASES    OF    BONE. 

Inflammatory  Affections. — For  descriptive  purposes, 
the  inflammatory  affections  of  bone  are  classified 
according  to  the  situation  of  the  lesion  into  three 
divisions  :  — 

(i)  Periostitis;  (2)  Osteitis;  (3)  Osteomyelitis. 

Strictly  speaking,  these  terms  imply  inflammation  of 
the  periosteum,  the  bone,  and  the  medullary  cavity, 
respectively.  But  it  is  important  to  realize  at  the 
outset  that  in  practice  no  such  definite  limits  exist. 
/  Where  the  periosteum  is  inflamed,  the  underlying 
^  bone  is  always  affected  to  a  greater  or  less  extent  while 
disease  involving  the  medullary  cavity  invariably 
affects  the  bone  surrounding  it.  In  a  similar  way,  if 
the  bone  itself  is  first  affected,  either  the  periosteum 
or  medullary  cavity,   or  both,  are  soon  involved.^ 

Necrosis  of  bone  means  the  death  of  a  definite  piece 
of  bone,  or,  in  other  words,  gangrene  of  bone  {q.v.). 
It  may  follov^  either  acute  or  chronic  disease  of  bone, 
and  results  in  the  complete  separation  of  the  necrotic 
portion;  the  separated  fragment  of  bone  is  known  as 
a  Sequestrum.  Tne  method  of  separation  oi  a  seques- 
trum is  similar  to  the  casting  of  a  slough.  Ulceration 
around  the  necrotic  portion  of  bone  occurs,  whereby 
a  line  of  separation  is  formed,  which  is  filled  up  by 
granulation  tissue;  this  is  due  to  inflammation  of  the 
living  tissue  nearest  to  the  necrotic  piece  (c/.  Gan- 
grene, Chapter  V). 

New  bone  is  subsequently  laid  down  around  the 
sequestrum.  This  new  bone  is  not  complete,  but  is 
pierced  by  several  holes.  The  new  bone  is  called  the 
involucrum,  and  the  holes  which  pierce  it  are  termed 
cloacce. 

*  Dental  students  must  be  careful  not  to  confuse  the  periostitis  here 
mentioned  with  dental  periostitis,  or,  more  properly,  periodontitis,  with 
which  it  has  nothing  whatever  to  do. 


DISEASES    OF    BONE  13[ 

Acute  Traumatic  Periostitis  is  an  acute  localized 
inflammation  of  the  periosteum  and  underlying  bone, 
following  injury.  An  open  wound  is  not  necessarily 
present.  In  slight  cases,  recovery  may  occur  without 
suppuration,  leaving  the  bone  somewhat  thickened. 
Wlien  the  mjury  is  severe,  or  when  infection  through 
an  open  wound  occurs,  pus  is  formed  between  tne 
periosteum  and  bone.  The  pus  strips  up  the  perios- 
teum off  the  bone,  leaving  a  small  surtace  of  bone 
uncovered  by  periosteum.  This  portion  of  bone  dies, 
and  is  thrown  off  as  a  sequestrum  by  the  process 
described  above. 

Clinical  Signs. — Severe  pain  is  present  at  the  site  of 
injury;  the  pain  usually  becoming  worse  at  night. 
The  part  is  tender  and  swollen.  If  suppuration 
occurs,  the  skin  is  red  and  inflamed.  If  the  pus  dis- 
charges through  the  skin,  a  sinus  results. 

Treatment. — In  the  non-suppurative  form,  complete 
rest  of  the  limb  in  an  elevated  position,  and  the  appli- 
cation of  fomentations  will  usually  suffice.  If  suppura- 
tion occurs,  the  pus  must  be  evacuated  by  means  of 
an  incision.  When  a  sequestrum  is  formed,  it  will 
require  to  be  removed  as  soon  as  it  is  completely 
separated;  the  process  of  sepai"ation  usually  takes  about 
six  weeks. 

Acute  Osteomyelitis  is  the  term  commonly  applied 
to  a  condition  which  affects  medulla,  bone,  and  perios- 
teum. It  commences,  as  a  rule,  either  in  the  medullary 
cavity   or   just   beneath  the   periosteum.      The  typical  / 

position  for  the  disease  to  begin  is  close  to  the  epi-      \j 
physial  line  on  the  shaft  side.     The  disease  is  common        V 
in  children,  either  after  an  acute  specific  fever  or  some    • 
slight  injury  in  a  debilitated  patient.     Some  time  ago 
it  was  a  frequent  sequela  of  amputation,  but  since  the 
introduction   of  aseptic  methods  this   complication   of 
amputation  has  practically  disappeared. 

Whether  the  disease  starts  centrally  or  beneath  the 
periosteum,  it  rapidly  involves  all  the  three  tissues, 
spreading  along  the  medulla,  and  also  stripping  up  the 
periosteum.  When  it  begins  in  its  typical  position,  the 
epiphysis  usually  escapes  altogether  on  account  of  its 
more  efficient  blood  supply.  In  certain  cases,  how- 
ever, the  disease  may  begin  in  the  epiphysis,  and 
remain    localized    there    (acute    epiphysitis).       If    the 


132  SURGERY    FOR    DENTAL    STUDENTS 

epiphysial   line   is   within   the   capsule   of   the   joint,    a 
septic  arthritis  will  probably  supervene. 

riie  most  common  organism  present  is  the  Staphy- 
lococcus aureus  or  albus.  Streptococcal  osteomyelitis 
is  rare. 

Clinical  Signs. — The  onset  is  sudden.  Severe  pain, 
tenderness,  redness  and  swelling  of  the  part  (generally 
in  a  limbj  are  present,  accompanied  by  marked  pyrexia, 
headache,  and  often  delirium.  Where  the  bone  is 
superficial  {e.g.,  the  tibia)  fluctuation  may  be  made  out. 
General  pyaemia  may  occur;  infective  emboli  may  pass 
off  in  the  blood-stream,  giving  rise  to  pyaemic 
abscesses,  malignant  endocarditis,  &c. 

Diagnosis. — This  condition  should  always  be  sus- 
pected in  a  child  with  pain  and  tenderness  in  a  limb 
bone,  especially  if  the  temperature  is  raised.  Growing 
pains  are  never  severe,  and  are  unaccompanied  by  any 
marked  constitutional  symptoms.  Acute  rheumatism 
is  very  rare  in  children. 

Treatment. — Immediate  operative  treatment  is  essen- 
tial. A  free  incision  must  be  made,  the  pus  evacuated, 
and  the  diseased  portions  of  bone  scraped  away.  If  it 
is  doubtful  whether  the  medullary  cavity  is  involved, 
it  may  be  wise  to  wait  twenty-four  hours  after  the  first 
incision  has  been  made  to  see  if  improvement  takes 
place.  It  is  clearly  undesirable  to  make  an  incision 
into  an  uninfected  medullary  cavity  and  thus  render  it 
liable  to  infection.  But  if  the  temperature  does  not 
fall  rapidly,  the  medullary  cavity  must  be  freely  opened 
up  and  scraped.  The  wound  should  be  plugged  with 
gauze  to  ensure  healing  from  the  bottom.  The  wound 
will  require  frequent  irrigation  with  hydrogen  peroxide ; 
the  limb  should  be  kept  at  rest,  a  splint  being  applied 
if  necessary. 

If  necrosis  occurs,  as  is  almost  invariably  the  case, 
the  wound  must  be  kept  open  until  the  separation  of 
the  sequestrum.  The  sequestrum  must  then  be  re- 
moved by  operation,  when  rapid  healing  will  occur. 

Amputation  is  required  in  certain  cases,  e.g.,  when 
the  occurrence  of  rigors  suggests  the  onset  of  pyaemia. 
But  the  decision  is  of  so  grave  a  nature  that  the 
greatest  experience  is  necessary. 

Chronic  Inflammation  of  Bone. —  Two  varieties  of 
chronic  inflammation  occur  in  bone,  vis.,  Raref active 
■Osteitis  and  Sclerosis. 


DISEASES     OF    BONE  I33 

Rarefactive  Osteitis  is  most  commonly  the  result  of 
tubercle.  Syphilis  is  a  less  frequent  cause,  while  the 
condition  may  also  result  from  the  pressure  of  a 
neoplasm  or  aneurysm.  The  solid  bone  becomes  ab- 
sorbed, and  replaced  by  granulation  tissue;  there  is- 
definite  increase  in  size  of  the  Haversian  canals,  which 
results  in  the  bone  being  lighter  than  usual.  When  a 
portion  of  bone  is  completely  replaced  by  granulation 
tissue  the  condition  is  known  as  Caries  (ulceration  of 
bone).  In  the  later  stages  the  granulation  tissue  may 
become  softened,  with  the  formation  of  an  abscess. 
Sequestra  are  often  formed. 

bcierosis  of  bone  is  practically  the  converse  of  the 
condition  just  described.  A  deposition  of  new  bone 
occurs,  both  beneath  the  periosteum  and  also  in  the 
Haversian  canals;  in  some  cases  the  Haversian  canals 
may  be  completely  obliterated  by  this  new  formation 
of  bone.  A  sclerosed  bone  will  naturally  be  heavier 
than  normal.  The  vascular  supply  is  interfered  with  to 
a  greater  or  less  extent;  this  interference  with  the  blood 
supply  may  result  in  necrosis  of  the  bone. 

The  most  common  causes  of  sclerosis  of  bone  are 
syphilis,  injury,  or  any  chronic  irritation  of  the  bone. 

In  some  cases  a  rarefactive  osteitis  may  occur  from 
inside  the  bone,  combined  with  sclerosis  beneath  the 
periosteum.  In  this  way  absorption  takes  place  from 
inside,  while  new  bone  is  laid  down  on  the  outside,  the 
result  being  that  expansion  of  the  bone  takes  place. 
The  amount  of  absorption  is  generally  greater  than  the 
sclerosis,  so  that  the  expanded  bone  becomes  quife 
thin.  The  most  usual  cause  of  this  condition  is  the 
presence  of  a  tumour  growing  from  the  inside,  and 
causing  absorption  of  the  bone,  the  sclerosis  beingf 
merely  an  attempt  on  the  part  of  Nature  to  compen- 
sate for  the  weakening  on  the  inside  by  a  new  forma- 
tion of  bone  on  the  outside. 

Chronic  inflammation  of  bone  may  depend,  there- 
fore, upon  some  injury  or  chronic  irritation.  In  these 
cases  it  is  usually  a  localized  sclerosis,  resembling  the 
condition  described  as  acute  traumatic  periostitis,  but 
differing  from  it  in  being  chronic  in  character.  Clinic- 
ally, the  condition  is  very  similar  to  the  acute  variety, 
the  signs  being  less  marked  and  the  onset  slower. 
Fever  is  often  absent  altogether. 


134  SURGERY    FOR    DENTAL    STUDENTS 

Treatment  consists  in  rest  of  the  affected  part;  if  a 
limb  is  involved  it  should  be  kept  in  an  elevated 
position.  Counter-irritation  to  the  part,  e.g.,  by  paint- 
ing the  skin  with  iodine,  may  be  useful.  For  the  relief 
of  pain  sodium  salicylate  gr.  x  should  be  given  inter- 
nally three  times  a  day. 

In  obstinate  cases,  where  pain  is  a  marked  feature, 
an  operation  for  the  removal  of  the  new-formed  bone 
may  be  required. 

Tuberculosis  of  Bone. — There  is  no  essential  differ- 
ence in  the  pathological  features  of  tuberculosis  in 
bone  from  the  condition  described  under  Tuberculosis 
(Chapter  XII).  The  grey  granulations  with  giant- 
cell  systems  appear,  later  on  undergoing  caseation  and 
softening.  There  is  often  more  irregularity  in  form 
when  the  disease  attacks  bone,  the  giant-cell  systems 
"being  consequently  more  difficult  to  demonstrate  under 
the  microscope.  Very  few  bacilli  are  to  be  found,  as 
.a  rule.  The  disease  most  frequently  begins  in  the 
cancellous  bone,  but  may  begin  under  the  periosteum 
or  in  the  medullary  cavity.  The  bone  is  destroyed  by 
a  rarefactive  osteitis,  resulting  in  caries. 

When  the  disease  commences  in  the  centre  and  runs 
a  very  chronic  course,  a  certain  amount  of  sclerosis  of 
the  surface  bone  often  occurs.  This  is  the  result  of 
the  chronic  irritation  of  the  disease,  but  is  not,  strictly 
speaking,  a  tuberculous  osteitis.  Sequestra  are  fre- 
quently formed  in  the  course  of  tuberculous  disease. 
■Clinically,  two  types  may  be  described  according  to  the 
position  in  which  the  disease  starts.  When  the  surface 
of  the  bone  is  first  affected,  a  painful  and  somewhat 
tender,  softish  swelling  may  be  made  out,  which  sooner 
or  later  undergoes  caseation  and  suppuration.  Slight 
fever  may  be  present. 

The  diagnosis  is  simple  as  soon  as  the  stage  of  casea- 
tion and  suppuration  is  reached,  but  in  the  early  stages 
it  may  be  very  difficult.  In  the  quite  early  stages  treat- 
ment is  carried  out  on  the  same  lines  as  for  a  simple 
chronic  periostitis,  so  it  is  not  of  such  great  importance 
to  make  a  definite  diagnosis;  but  the  possibility  of 
tubercle  should  always  be  borne  in  mind. 

General  hygienic  treatment,  as  described  under 
Tuberculosis  (Chapter  XIIj,  will  be  required,  and 
rest  and  counter-irritation  of  the  part  by  means  of 
iodine  or  Scott's  dressing  may  be  tried. 


DISEASES    OF    BONE  I35 

As  soon  as  there  is  any  sign  of  suppuration,  a  free 
incision  should  be  made  and  the  pus  evacuated. 

The  second  cHnical  variety  is  that  in  which  the 
disease  commences  in  the  medullary  cavity.  There  is 
severe  aching  pain,  worse  at  night,  and  some  general 
swelling  of  the  part,  with  slight  fever.  Later  on, 
when  suppuration  occurs,  a  point  on  the  skin  becomes 
red  and  tender  where  the  abscess  is  pointing.  The 
diagnosis  is  extremely  difficult  to  make  with  certainty 
until  suppuration  occurs,  though  the  condition  should 
always  be  suspected.  The  treatment  is  the  same  as 
for  the  superficial  variety. 

Tuberculosis  of  the  Bones  of  the  Face  does  not  differ 
in  symptoms  or  treatment  from  the  disease  in  other 
bones.  The  most  common  situations  in  the  face  are: 
the  lower  margin  of  the  orbit;  the  frontal  and  nasal 
bones;  the  nasal  processes  of  the  superior  maxilla, 
and  the  alveolar  processes  of  either  jaw;  the  presence 
of  carious  teeth  is  said  to  predispose  to  this  latter 
condition. 

Syphilis.— In  the  early  secondary  stages  indefinite 
aching  pains  in  the  bones  may  occur.  Later  on,  in  the 
secondary  stage,  sclerotic  periostitis  often  occurs, 
especially  affecting  the  long  bones,  such  as  the  tibia. 
It  is  very  similar  to  a  simple  chronic  inflammation;  it 
may  be  diffuse  in  character,  but  more  commonly  occurs 
in  patches,  which  are  termed  nodes.  Clinically,  the 
disease  gives  rise  to  deep-seated,  aching  pains,  which 
are  worse  at  night.  There  is  often  definite  enlarge- 
ment of  the  bone  to  be  made  out,  and  this  swelling  may 
be  somewhat  tender. 

In  the  tertiary  stage  two  clinical  varieties  occur :  — 

(i)  A  diffuse  sclerosis  of  the  bone,  both  beneath  the 
periosteum  and  in  the  medullary  cavity.  The  bones 
of  the  skull  are  most  commonly  affected  by  the  diffuse 
variety. 

(2)  Multiple  gummata,  generally  subperiosteal, 
giving  rise  to  absorption  of  the  bone  (syphilitic  caries). 
This  type  is  also  common  in  the  cranial  bones,  often 
giving  rise  to  extensive  necrosis. 

The  treatment  of  these  conditions  is  carried  out  on 
general  antisyphilitic  lines  {vide  Chapter  XII). 

In  the  congenital  variety,  enlargement  of  the  ends 
of  the  long  bones   {syphilitic  epiphysitis)  may   occur; 


136  SURGERY    FOR    DENTAL    STUDENTS 

and  also  a  condition  in  which  the  cranial  bones  are 
markedly  absorbed  in  localized  patches,  resulting  in  a 
condition  of  Craniotabcs  similar  to  that  described  as 
occurring-  ni  Rickets. 

The  Bones  of  the  Face  are  rarely  affected  by  the 
diffuse  variety.  Gummata  are  fairly  common,  most 
usually  spreading  to  the  bone  from  the  surrounding 
•     soft  parts,  such  as  the  nose,  palate,  &c. 

Phosphorus  necrosis  of  the  jaw  is  described  in 
Chapter  XXIII. 

There  are  several  rare  diseases  of  bone  which, 
though  of  great  interest,  do  not  come  within  the  scope 
of  a  handbook  of  this  description. 

Tumours  of  Cartilage  and  Bone. 
(A)  Simple  Tumours. 

(1)  A  Chondroma  is  a  tumour  composed  chiefly  of 
cartilage.  These  tumours  are  usually  small  and  mul- 
tiple. They  commonly  occur  around  the  metacarpals 
and  phalanges,  but  may  appear  in  other  situations, 
such    as    the    cartilages    of    the    nose    or    larynx,    or 

/  even  the  parotid  gland.  (The  presence  of  a  neoplasm, 
•J  consisting  chiefly  of  cartilage  in  the  parotid  gland,  has 
been  explamed  as  being  a  remnant  of  the  cartilage  of 
one  of  the  branchial  arches.)  Calcification,  and  even 
ossification,  may  occur  in  these  tumours.  They  are 
not  painful,  and  do  not  commonly  become  malignant, 
so  that  no  treatment  will  be  required  unless  the  de- 
formity they  cause  renders  their  removal  advisable. 

Single  chondromata  may  occur  at  or  near  the  ends 
of  long  bones;  this  variety  undergoes  ossification 
early,  and  is  merely  the  first  stage  in  the  development 
of  the  spongy  osteoma  described  below. 

(2)  Osteoma. —  Two  distinct  varieties  of  osteomata, 
or  tumours  consisting  chiefly  of  bone,  are  met  with. 

{a)  The  spongy  osteoma,  or  exostosis,  is  a  single, 
^  pedunculated  bony  tumour  affecting  the  ends  of  long 
bones.  In  rare  cases  multiple  exostoses  occur.  As 
mentioned  above,  these  tumours  begin  as  chondromata, 
and,  even  when  completely  ossified,  there  remains  a  cap 
of  hyaline  cartilage  on  the  surface  of  the  growth. 

The  treatment  required  is  removal,  if  unpleasant 
symptoms  such  as  pain  are  caused. 

{b)  Ivory  exostoses  are  sessile  masses  of  very  hard, 


DISEASES    OF    BONE  137 

dense,  compact  bone  chiefly  affecting"  the  bones  of  the 
vault  of  the  skulL 

Treatment  is  not  required  as  a  rule.  If  the  tumour 
is  causing  alarming  symptoms  from  pressure  on  the 
contents  of  the  skull,  an  attempt  must  be  made  to 
remove  it. 

(3)  Fibromata  arising"  from  the  periosteum  occur  in 
two  common  forms :  Epulis,  affecting  the  jaw  (vide 
Chapter  XXIII),  and  Nasopharyngeal  polypus,  grow- 
ing from  the  basilar  portion  of  the  occipital  bone. 
These  latter  tumours  often  become  sarcomatous,  and 
for  this  reason  they  should  under  all  circumstances  be 
removed  at  once. 

(B)  Malignant  Tumours. 

Periosteal  Sarcomata  are  those  which  commence  in 
the  periosteum.  They  may  consist  either  of  round  or 
spindle  cells,  or  may  be  of  the  mixed  variety.  They  do 
not  cause  much  pain,  but  grow  very  rapidly,  and  are 
extremely  malignant,  secondary  growths  in  the  viscera 
occurring  early.  Ossification  in  the  tumour  often  takes 
place,  and  spontaneous  fracture  may  occur. 

Central  sarcomata  commence  deep  in  the  bone;  they 
are  usually  of  the  round-celled  variety,  but  may  be 
spindle-celled  or  mixed.  They  cause  more  pain  than 
the  periosteal  variety  on  account  of  the  expansion  of 
the  bone  w^hich  occurs.  This  process  of  expansion  of 
the  bone  has  been  described  above  on  page  133.  These 
sarcomata  grow  with  great  rapidity,  and  are  very 
malignant. 

The  diagnosis  is  often  very  difficult  in  the  early 
stages.  Considerable  assistance  may  be  obtained  from 
X-rays.  The  great  thinning  of  the  bone  which  occurs 
in  the  process  of  expansion  results  in  a  curious  crack- 
ling" sensation  when  the  tumour  is  palpated.  This  is 
known  as  eggshell  crackling,  and  is  an  important  aid 
to  diagnosis. 

Treatment. — Amputation  at  a  point  w^ell  above  the 
seat  of  the  growth  gives  the  only  possible  hope  of  cure. 
But  secondary  growths  are  formed  so  early  that  the 
disease  is  almost  always  fatal. 

Myeloid  Sarcoma. — This  variety  of  neoplasm  almost 
invariably  occurs  in  bone.  Considerable  difference  of 
opinion  exists  as  to  whether  or  not  this  tumour  should 


138  SURGERY    FOR    DENTAL    STUDENTS 

be  classed  among  the  malignant  neoplasms.  Secondary 
growths  are  of  great  rarity;  some  authorities  deny  that 
secondary  growths  are  ever  formed,  and  on  this 
account  class  the  tumour  among  the  simple  neoplasms 
under  the  name  of  Myeloma.  It  is  very  much  slower 
in  growth  than  the  ordinary  sarcoma.  Microscopically, 
the  growth  consists  of  round  and  spindle  cells,  in  addi- 
tion to  which  large,  irregular  multinucleate  giant  cells 
occur.  These  tumours  are  very  soft  and  vascular, 
often  consisting  of  large  cavities  full  of  blood.  Clinic- 
ally, there  is  usually  some  pain  and  swelling,  'but  in 
some  cases  no  signs  may  appear  until  a  late  stage, 
when  spontaneous  fracture  may  reveal  the  condition, 
hitherto  unsuspected. 

The  treatment  is  complete  and  free  removal.  If  the 
removal  is  complete,  recurrence  is  rare. 

Secondary  carcinomata  and  sarcomata  are  common 
in  the  bones,  especially  in  cases  of  carcinoma  of  the 
thyroid  or  prostate,  and  in  the  melanotic  variety. 

Tumours  of  Bones  of  the  Face. —  Simple  tumours  are 
rare  with  the  exception  of  fibrous  epulis. 

Malignant  tumours  are  fairly  common;  carcinoma, 
rodent  ulcer,  sarcoma  and  myeloid  sarcoma  may  all 
occur. 


CHAPTER    XVIII. 

INJURIES    OF    JOINTS. 

Wounds. —  The  severity  of  wounds  which  involve 
joints  depends  chiefly  upon  the  cleanhness  of  the 
instrument  by  which  the  wound  is  inflicted.  A  clean 
wound  is  foflowed  by  a  simple  synovitis  which,  if 
treated  aseptically,  commonly  heals  rapidly.  A  careful 
watch  must  be  kept  for  any  sign  of  sepsis.  If  a  joint 
is  wounded  by  a  dirty  instrument,  operative  interfer- 
ence will  be  required  immediately.  The  joint  should 
be  opened,  carefully  washed  out,  and  rendered  aseptic. 
If  this  be  not  done,  a  septic  arthritis  (inflammation  of 
joint)  will  ensue,  and  the  subsequent  treatment  be 
difficult  and  tedious. 

Sprains  and  Strains  include  injuries  resulting  in 
tearing  or  stretching  of  ligaments,  synovial  membrane, 
or  other  structures  in  immediate  relation  to  the  joint. 
They  are  due,  as  a  rule,  to  sudden  violence.  Con- 
siderable pain  and  tenderness  are  present,  usually 
accompanied  by  swelling  and  discoloration  of  the  part. 
Traumatic  synovitis  commonly  supervenes. 

It  is  important  to  distinguish  these  injuries  from 
dislocations  and  fractures;  and  the  diagnosis  may  be 
rendered  difficult  owing  to  the  great  tenderness  of  the 
part,  and  consequent  impossibility  of  thorough  physical 
examination.  The  chief  point  to  bear  in  mind  is  that 
the  anatomical  landmarks  will  be  in  their  normal  posi- 
tions. The  aid  of  X-rays  is  often  of  considerable  value 
in  diagnosis. 

Treatment. — The  injured  part  should  be  dressed  with 
lead  lotion  and  firmly  bandaged  to  limit  as  far  as 
possible  the  effusion  of  fluid  into  the  joint.  Massage 
and  passive  movements  should  be  resorted  to  as  soon 
as  possible,  but  this  will  naturally  depend  upon  the 
severity  of  the  injury. 

Dislocations. — When  two  or  more  bones  that  nor- 
mally combine  to  form  a  joint  become  sufficiently 
disarranged    to    refuse    to    reassume    naturally    their 


140  SURGERY    FOR    DENTAL    STUDENTS 

proper  relationship  the  condition  is  called  a  dislocation. 
Dislocations  are  classified  according  to  their  cause,  into 
three  divisions:  — 

(Ij  Congenital  Dislocations :  due  to  some  abnormal 
development  or  to  injury  in  utero.  It  w^ill  be  unneces- 
sary to  discuss  these  further. 

{z)  Pathological  Dislocations :  dependent  upon 
disease  of  the  joint  (vide  Chapter  XIX). 

(3)  Traumatic  Dislocations. — It  is  important  that 
the  dental  surgeon  should  be  possessed  of  some  know- 
ledge of  these  conditions,  as  an  emergency  may  easily 
occur  in  which  he  may  be  required  suddenly  to  deal 
with  a  case.  Though  this  is  particularly  true  in  dislo- 
cation of  the  mandible,  the  student  should  endeavour 
to  make  himself  familiar  with  dislocations  of  other 
joints. 

Predisposing  Causes  :    (i)  Age. — Traumatic  disloca- 
tions are  rare   in  childhood  and  in  old  age.     This  is 
due  to  the  greater  frequency  of  fracture  in  old  age 
and  of  separation  of  epiphyses  in  childhood. 

(2)  Anatomical  Features. — Certain  joints  are  much 
easier  to  dislocate  than  others.  The  shallow  glenoid 
cavity  of  the  scapula  and  the  comparative  laxity  of  its 
ligaments  renders  dislocation  of  the  shoulder-joint  a 
commoner  injury  than,  for  example,  a  similar  injury 
to  the  hip-joint,  where  the  head  of  the  femur  is  received 
into  a  deep  socket  and  supported  by  strong  ligaments. 

(3)  Previous  disease  in  a  joint  may  predispose  to 
dislocation. 

Exciting  Causes. — Dislocations  are  most  commonly 
due  to  indirect  violence,  associated  with  sudden  mus- 
cular contraction.  Direct  violence  is  a  less  frequent 
cause;  while  in  a  still  fewer  number  of  cases,  muscular 
contraction  alone,  without  any  external  violence, 
results  in  dislocation.  The  joints  in  which  the  injury 
follows  muscular  contraction  alone  are  chiefly  the 
temporo-maxillary  and  the  shoulder-joint.  The  patella 
may  also  be  dislocated  in  a  similar  manner. 

Dislocations  are  classified  in  various  ways:  — 

A. — (i)  Complete:  when  the  articular  surfaces  are 
quite  separated. 

(2)  Incomplete :   when  the  articular  surfaces  are  only 
partially  separated. 
(or) 


INJURIES      OF     JOINTS  I4I 

B. — {_!)  Simple:    when  the  skin  is  unbroken. 

(2)  Compound :  when  the  skin  is  broken  {cf.  Frac- 
tures). 

When  injuries  to  vessels,  nerves,  &c.,  occur  the  dis- 
location is  called  complicated.  If  a  fracture  is  also 
present,  the  injury  is  known  as  a  fracture-dislocation. 

General  Signs— 

(i)  History  of  injury. 

(2)  Great  pain  and  swelling. 

(3)  Immobility  of  limb,  if  no  fracture  be  present. 

(4)  Loss  of  power  of  movement. 

(5)  Deformity.  On  comparing  the  injured  with  the 
sound  limb,  the  bony  points  will  be  found  to  be  dis- 
placed. 

(6)  Alteration  of  length  of  limb. 

Diagnosis— 

(a)  Fro7n  a  Sprain. — The  deformity,  loss  of  power 
of  movement,  and  alteration  in  length  of  limb  are  im- 
portant points  in  favour  of  dislocation. 

(b)  From  Fracture. — The  immobility  of  the  limb, 
and  the  position  of  the  bony  points  must  be  noted. 
An  X-ray  examination  should  always  be  made  in  all 
cases  of  injury  near  a  joint,  if  the  apparatus  is  at  hand. 

Treatment. — Immediate  reduction  of  the  dislocation 
is  the  first  essential  in  the  treatment.  The  delay,  even 
of  an  hour  or  so,  will  allow  the  accumulation  of  a 
considerable  amount  of  fluid  in  the  joint,  which  will 
render  the  subsequent  treatment  much  more  difficult. 
The  particular  manipulations  required  to  effect  reduc- 
tion naturally  vary  with  the  position  of  the  injury,  but 
as  a  general  rule,  the  object  of  the  surgeon  is  to  cause 
the  displaced  bone  to  return  by  the  way  it  came.  The 
administration  of  an  anesthetic  may  be  required,  more 
to  overcome  the  muscular  resistance,  than  to  avoid 
discomfort  to  the  patient.  In  a  simple,  uncomplicated 
dislocation,  operative  treatment  is  rarely  required. 

Passive  movements  and  massage  should  be  begun  in 
most  cases,  in  twenty-four  hours'  time,  and  active 
movements  soon  after;  though  these  limits  may  have 
to  be  exceeded  in  certain  cases. 

Fracture  Dislocations. — The  dislocation  should  be 
reduced  first  and  the  fracture  set  afterwards.     Opera- 


142  SURGERY    FOR    DENTAL    STUDENTS 

tive  interference  is  often  required  to  attain  both  these 
objects. 

Compound  Dislocations  are  rare,  except  as  part  of 
a  very  severe  injur}^;  they  are  usually  complicated  by 
fracture  and  by  severe  injury  to  soft  parts. 

Operation  is  always  required  {vide  supra,  Septic 
wounds  of  joints),  and  in  many  cases  it  may  be  neces- 
sary to  resort  to  amputation. 

Special  Dislocations- 
Mandible. — The  mandible  is  most  commonly  dis- 
located forwards;  the  injury  may  be  unilateral  or  bi- 
lateral. It  usually  occurs  as  the  result  of  a  blow  on 
the  chin  when  the  mouth  is  slightly  open;  in  some 
cases  muscular  action  alone  may  be  sufficient.  The 
injury  has  occurred  during  the  extraction  of  teeth, 
when  the  operator  has  not  been  careful  to  support  the 
mandible.  In  some  patients,  where  the  glenoid  fossa 
is  unusually  shallow,  and  the  ligaments  weak,  very 
little  force,  such  as  yawning  or  excessive  opening  of 
the  mouth  by  a  prop  or  Mason's  gag,  may  be  sufficient 
to  bring  about  a  dislocation,  especially  where  such  an 
injury  has   occurred  before. 

Mechanism. — In  the  normal  movement  of  opening 
the  mouth,  the  condyle,  accompanied  by  the  inter- 
articular  fibro-cartilage,  moves  forwards  out  of  the 
glenoid  fossa,  on  to  the  eminentia  articularis.  If  this 
normal  movement  be  increased,  the  condyle  is  dis- 
placed further  forwards  into  the  zygomatic  fossa,  where 
it  is  fixed  by  the  action  of  the  masseter  and  temporal 
muscles.  As  a  rule,  the  inter-articular  fibro-cartilage 
does  not  follow  the  condyle  as  far  as  this. 

Clinical  Signs. —  The  bilateral  variety  is  most  com- 
mon. The  mouth  is  slightly  open,  the  mandible  being 
protruded  and  fixed.  There  is  usually  considerable 
pain;  and  saliva  dribbles  away  uncontrolled.  In  the 
positions  where  the  condyles  of  the  jaw  are  normally 
to  be  felt,  definite  hollows  can  be  detected,  while  the 
condyles  can  be  felt  in  their  new  position,  further  for- 
ward. It  is  often  possible,  with  the  aid  of  a  finger  in- 
side the  mouth,  to  feel  the  coronoid  process  in  front 
of  its  normal  position.  The  signs  of  a  unilateral  dis- 
location  are  similar  but  less  marked.  The  jaw  is  not 
absolutely  fixed,  and  is  displaced  tozvards  the  sound 
side. 


INJURIES      OF     JOINTS  143 

Treatment. — To  reduce  the  dislocation,  the  condyle 
must  be  made  to  return  the  way  it  came;  that  is  to 
say,  it  must  be  depressed  below  the  level  of  the 
eminentia  articularis,  when  muscular  action  will  draw 
it  backwards  into  the  glenoid  fossa.  An  anaesthetic  is 
not  generally  required.  The  patient  should  be  seated 
in  a  chair,  and  the  surgeon,  standing  in  front,  places 
his  thumbs,  protected  by  wrapping  napkins  around 
them,  upon  the  lower  molar  teeth,  and  makes  pressure 
downwards.  Considerable  pressure  may  be  required 
before  the  resistance  of  the  masseters  and  temporals 
can  be  overcome.  When  the  condyles  have  been  de- 
pressed far  enough,  and  the  jaw  is  felt  to  yield,  the 
chin  must  be  raised  with  the  palm  of  the  hand,  and 
pushed  backwards.  The  condyles  will  then  slip  back 
into  place,  often  with  a  definite  snap.  It  is  at  this 
period  of  the  operation  that  the  surgeon's  thumbs  are 
in  danger  of  an  injury,  from  the  sudden  closure  of 
the  jaws,  hence  the  precaution  of  wrapping  them  in 
napkins  or  lint.  It  is  wiser,  if  possible,  to  slip  the 
thumbs  outwards  into  the  space  between  the  cheek  and 
the  teeth,  at  the  last  moment;  but  the  pressure  on  the 
molar  teeth  must  not  be  relaxed  too  soon,  and  it  is 
better  to  move  the  thumbs  too  late  than  too  early. 
This  dislocation  is  very  prone  to  recur,  and  great  care 
must  therefore  be  taken.  A  four-tail  bandage  should 
be  so  applied  that  the  mouth  can  be  sufficiently  opened 
to  allow  of  fluids  being  taken  :  an  elastic  four-tail  band- 
age is  very  useful,  as  it  allows  a  little  movement,  but 
not  much.  This  treatment  must  be  continued  for  at 
least  a  week,  and  the  patient  must  be  instructed  to 
exercise  great  care  in  mastication,  and  in  such  move- 
ments as  those  involved  in  laughing  or  yawning,  for 
several  weeks.  Even  with  all  these  precautions, 
patients  to  whom  this  accident  has  once  occurred  are 
very  liable  to  a  recurrence  of  the  condition  on  very 
slight  provocation.  In  these  cases  of  recurrent  dislo- 
cation, reduction  becomes  proportionately  easy,  some 
patients  becoming  quite  expert,  from  personal  experi- 
ence, in  reducing  their  own  dislocations. 

When  a  dislocation  of  the  mandible  has  been  left 
unreduced  for  any  length  of  time,  considerable  ad- 
hesions will  often  form  in  the  joint.  These  adhesions 
must  be  broken  down  under  an  anaesthetic,  and  an 
attempt  made  to  reduce  the  dislocation.     These  efforts 


144  SURGERY    FOR    DENTAL    STUDENTS 

are  often  successful  even  after  two  or  three  months. 
If  they  fail,  the  condyle  must  be  excised. 

The  Shoulder-joint  is  more  frequently  dislocated  than 
any  other;  this  is  due  partly  to  the  anatomical  features 
of  the  joint,  to  which  attention  has  been  drawn  above 
(p.  140),  and  also  to  the  fact  that  the  most  frequent 
cause  of  the  injury  (viz.,  a  fall  on  the  outstretched 
hand  or  elbow)  is  a  very  common  occurrence. 

The  head  of  the  humerus  passes  out  through  the 
anterior  inferior  part  of  the  capsule,  and  comes  to  lie 
below  the  glenoid  cavity.  Here  it  may  remain  (Sub- 
glenoid dislocation)',  but  much  more  commonly  it 
passes  forwards  and  comes  to  lie  beneath  the  coracoid 
process  (Sub-coracoid  dislocation).  If  the  force  of  the 
injury  is  very  violent,  still  further  displacement  may 
occur,  the  head  of  the  bone  passing  forwards  to  a 
position  beneath  the  clavicle  (Subclavicular  disloca- 
tion). In  much  rarer  instances,  the  displacement  is 
backwards  into  the  infraspinous  fossa  (Subspinous 
dislocation). 

Clinical  Si^ns. — The  following  signs  are  common  to 
all  the  above  forms  of  dislocation  of  the  shoulder:  — 

(a)  The  shoulder  is  flattened,  owing  to  the  absence 
of  the  head  of  the  humerus  from  its  normal  position. 

(b)  The  acromion  process  is  unusually  prominent, 
with  a  hollow  beneath  it. 

(c)  The  head  of  the  humerus  may  be  felt  in  its  new 
position,  which,  of  course,  varies  according  to  the 
form  of  dislocation  present. 

(d)  If  the  hand  (on  the  injured  side)  is  placed  on 
the  opposite  shoulder,  the  elbow  sticks  outwards,  and 
cannot  be  made  to  touch  the  side  of  the  chest. 

(e)  The  vertical  measurement  through  the  axilla  is 
increased;  that  is  to  say,  it  is  greater  on  the  injured 
than  on  the  sound  side. 

(/)  Signs  of  pressure  on  vessels  or  nerves  may  be 
present. 

In  a  subcoracoid  dislocation:  — 

(g)  The  elbow  is  displaced  outwards  and  backwards. 

(h)  The  head  of  the  humerus  is  felt  beneath  the 
coracoid  process. 

(/)  There  is  no  noticeable  alteration  in  the  length 
of  the  arm. 

(k)  The  subscapularis  muscle  is  often  torn. 


INJURIES      OF     JOINTS  I45 

In  a  sub  clavicular  dislocation:  — 

(g)  The  elbow  is  again  displaced  outzvards  and  back- 
wards. 

(h)  The  head  of  the  bone  is  more  difficult  to  feel, 
under  the  pectoralis  major,  lying  upon  the  second  and 
third  ribs. 

(;)  There  is  definite  shortening  of  the  arm. 

(k)  The  coracoid  process  may  be  fractured,  or  the 
great  tuberosity  of  the  humerus  torn  off. 

In  a  subglenoid  dislocation:  — 

(g)  The  elbow  is  again  displaced  outwards  and  back- 
wards, but  not  so  markedly  as  in  the  two  previous 
cases. 

(h)  The  head  of  the  humerus  is  felt  in  the  axilla. 

(;)  The  arm  is  slightly  lengthened. 

(k)  Pressure  signs  are  generally  marked :  there  is 
often  great  pain  from  pressure  on  the  brachial  plexus, 
and  the  radial  pulse  may  be  diminished,  or  even 
absent. 

In  a  subspinous  dislocation  :  — 

(g)  The  elbow  is  displaced  forzvards  and  slightly 
outwards. 

(h)  The  head  of  the  humerus  may  be  felt  at  the 
back,  below  the  spine  of  the  scapula. 

(j)  There  is  no  definite  alteration  in  the  measurement 
of  the  arm. 

(k)  The  arm  is  rotated  in,  and  the  hand  throv.m 
across  the  chest. 

Treatment — A  simple  dislocation  should  be  at  once 
reduced.  This  may  be  effected  by  manipulation  or 
traction. 

(a)  Manipulation  should  be  attempted  first.  An 
anaesthetic  should  be  administered,  whenever  possible. 
In  some  cases,  especially  where  the  patient  is  seen 
immediately  after  the  injury,  reduction  may  occur 
spontaneously  as  soon  as  the  patient  is  under  the 
anaesthetic. 

Various  methods  of  reducing  this  dislocation  have 
been  devised,  only  one  of  which  (Kocher's  method) 
need  be  considered  here. 

The  patient,  if  unanaesthetized,  should  be  seated  in 

a   chair;   if   anaesthetized,    he   should   be   lying   on   his 

back.     An     assistant,    standing    behind    the     patient, 

should  fix  the  trunk   and  the   scapula.     The  surgeon 

10 


146  SURGERY    FOR    DENTAL    STUDENTS 

stands  in  front  of  the  patient,  flexes  the  forearm  to 
a  right  angle,  and  presses  the  elbow  firmly  against  the 
side  of  the  chest.  This  movement  brings  the  head  of 
ithe  humerus  against  the  edge  of  the  glenoid  cavity. 
The  arm  should  then  be  steadily  rotated  outwards  as 
far  as  possible.  During  this  movement,  the  head  of 
the  humerus  rotates  along*  the  edge  of  the  glenoid 
cavity,  and  not  in  the  axis  of  the  humerus.  This  move- 
ment may  suffice  to  reduce  the  dislocation.  If  not, 
the  arm,  still  fully  rotated  out,  should  be  brought 
upwards  and  forwards,  almost  to  a  right  angle,  keep- 
ing" the  elbow  towards  the  chest  during  the  process. 
This  movement  relaxes  the  capsule.  The  arm  must 
then  be  sharply  rotated  inwards,  so  that  the  hand  goes 
towards  the  opposite  shoulder  and  the  arm  is  brought 
across  the  chest.  This  movement  generally  brings 
about  reduction.  The  arm  is  then  fixed  to  the  side, 
and  supported  in  a  sling. 

It  is  almost  impossible  to  get  a  clear  idea  of  this 
complex  series  of  movements  from  a  description  in  a 
book;  the  student  should  make  a  point  of  seeing  the 
operation  performed  on  the  living  subject. 

(b)  Traction  must'  be  resorted  to,  if  the  above 
method  fails.  An  anaesthetic  must  be  given.  The  sur- 
.i^eon  places  his  knee  or  his  heel  (without  a  boot)  in 
the  axilla  as  a  fulcrum,  and,  grasping"  the  arm  at  the 
wrist,  makes  traction  downwards  and  little  outwards, 
the  heel  in  the  axilla  pressing  slightly  outwards  the 
wliile.  Traction  must  be  steady,  never  jerky.  When 
the  muscular  resistance  is  felt  to  have  been  overcome, 
tlie  arm  is  carried  inwards  across  the  trunk,  the  heel 
still  being  kept  in  the  axilla,  and  the  head  of  the  bone 
usually  slips  into  place. 

This  dislocation  is  apt  to  recur  from  any  slight  in- 
jury. The  limb  should  therefore  be  kept  in  a  sling 
during  the  day;  at  night  it  should  be  secured  by  a 
broad  bandage  around  chest  and  arm. 

Passive  movements  and  massage  should  be  begun 
on  the  next  day;  but  the  arm  should  not  be  abducted 
for  at  least  a  fortnight. 

After  a  day  or  two,  the  patient  may  be  allowed  to 
use  the  arm  as  far  as  he  can  while  it  is  in  the  sling. 
but  should  not  take  it  out  of  the  sling,  nor  attempt 
to  abduct  it. 


INJURIES      OF     JOINTS  J  4/ 

Complications — 

Fracture. — If  possible,  that  is,  if  the  fracture  is  not 
high  up,  the  dislocation  should  be  reduced  first,  and 
then  the  fracture  treated.  If  this  is  not  possible, 
operative  interference  will  be  required.  The  fracture 
nuist  never  be  put  up  while  the  dislocation  is  left  un- 
reduced. 

Injury  to  axillary  vessels  or  nerves  may  require 
operative  treatment.  Immediate  control  of  haemor- 
rhage may  be  required  if  the  axillary  artery  be  torn. 
The  shoulder  should  be  forcibly  depressed,  and  the 
subclavian  artery  compressed  against  the  first  rib  by 
means  of  a  key  wrapped  in  lint.  Compound  disloca- 
tion of  the  shoulder-joint  is  rare,  and  usually  necessi- 
tates amputation. 

The  above  two  dislocations  have  been  treated  some- 
what in  detail,  as  they  are  specially  mentioned  in  the 
syllabus  issued  by  the  Royal  College  of  Surgeons  of 
England.  The  injuries  of  the  remaining  joints  will  be 
treated  much  more  briefly;  details  of  displacements  of 
bones  being  largely  omitted,  as  the  student's  anatomi- 
cal knowledge  should  enable  him  to  supply  these  for 
himself. 

Elbow  joint. —  Dislocations  of  this  joint  are  fairly 
common  in  young  people.  The  injury  may  result  in 
displacement  of  both  radius  and  ulna,  or  of  one  bone 
alone.  The  most  common  variety  is  a  dislocation  of 
botJi  bones  backwards.  In  this  case,  the  displacement 
of  the  bones  is  quite  easy  to  determine.  The  arm  will 
be  immobile,  unless  the  dislocation  is  associated  with  a 
fracture  of  the  ^coronoid  process. 

Treatment. — If  possible,  an  anaesthetic  should  be 
employed.  The  surgeon  stands  in  front  of  the  patient, 
and  placing  his  knee  in  the  bend  of  the  elbow,  makes 
steady  traction  until  the  muscular  resistance  is  over- 
come, and  flexes  the  arm  across  his  knee.  This  is 
usually  sufficient  to  reduce  the  dislocation.  A  disloca- 
tion of  the  radius  and  ulna  foi'wards  may  occur,  usuallv 
accompanied  by  fracture  of  the  olecranon  process.  It 
should  be  treated  in  the  same  way  as  the  backward 
dislocation. 

Lateral  dislocations  are  rare. 

After  a  dislocation  of  the  elbow  has  been  reduced, 
the  arm  should  be  kept  In  a  sling,  but  massage  and 
passive  movements  should  be  employed  early. 


148  SURGERY    FOR    DENTAL    STUDENTS 

Pulled  elbow  is  a  frequent  occurrence  in  young 
children.  It  is  characterized  by  severe  pain,  the  arm 
being"  firmly  fixed  in  a  position  midway  between  pro- 
nation and  supination.  It  is  often  the  result  of  lifting 
a  child  up  by  its  wrists.  Various  theories  have  been 
put  forward  as  to  the  exact  anatomical  injury  that 
occurs. 

Treatment. — The  arm  should  be  grasped  at  the  wrist 
and  steadily  supinated.  Some  surgeons  are  of  opinion 
that  pronation  is  the  better  method  of  treating  the 
condition. 

Wrist.  —Dislocations  forwards  and  backwards  occur. 
Neither  condition  is  common.  It  is  important  to 
diagnose  between  a  dislocation  of  the  wrist  and  a 
fracture  of  the  lower  end  of  the  radius  (Colles's  frac- 
ture) :  the  latter  injury  is  a  very  common  one.  If  the 
injury  in  question  is  a  dislocation  the  styloid  processes 
of  the  radius  and  ulna  will  be  in  their  normal  relation 
to  one  another;  the  hand  will  not  be  displaced  out- 
wards, and  the  lower  ends  of  the  radius  and  ulna  will 
be  palpable  under  the   skin. 

Treatment. — The  surgeon  should  hold  the  patient's 
hand,  and  at  the  same  time  grasp  the  forearm  and 
make  steady  traction.  An  anaesthetic,  if  available,  will 
render  reduction  easier.  It  is  wise  to  apply  an  anterior 
splint  for  a  few  days. 

The  first  phalanx  of  the  thumb  may  be  dislocated  by 
a  fall  on  the  abducted  thumb,  the  base  of  the  phalanx 
being  displaced  backwards. 

Treatment. — The  metacarpal  bone  should  be  firmlv^ 
flexed  against  the  palm  of  the  hand,  while  the  phalanges' 
are  hyper-extended.  Steady  traction  should  be  made 
on  the  phalanges.  The  base  of  the  first  phalanx  should 
then  be  pushed  forwards,  and  the  whole  thumb  flexed 
against  the  palm.  This  method  is  by  no  means  in- 
variably successful,  and  operative  measures  may  be 
required. 

Hip -joint. — Several  varieties  of  dislocation  of  this 
joint  are  described.  It  will  be  sufficient  to  remember 
that  there  are  two  classes:  — 

(i)  The  head  of  the  femur  displaced  backwards  either 
on  to  the  dorsum  of  the  ilium  (Dorsal  dislocation)  or 
ijnto   the    sciatica   notch    (Sciatic   dislocation). 

(2)  The  head  of  the  femur  displaced  forwards  either 


INJURIES      OF     JOINTS  I49 

into  the  obturator  foramen  {Obturator  dislocation)  or 
on  to  the  front  of  the  pubes  {Pubic  dislocation).  Great 
violence  is  necessary  to  bring  about  a  dislocation  in  a 
healthy  hip-joint,  and  the  condition  is  consequently 
uncommon.  The  thigh  is,  as  a  rule,  flexed  and  ab- 
ducted at  the  time  when  the  injury  occurs. 

•Posterior  Dislocation— 

Signs. — (i)  The  limb  is  flexed,  adducted  and  inverted, 
{2)  There  is  a  hollow  in  Scarpa's  triangle. 
(3J  The   head   of  the   femur   is   felt   on   the 
dorsum  ilii  or  in  the  sciatic  notch.     It  is 
not  easy  to  feel  in  these  positions. 

(4)  The  great  trochanter  is  raised  above 
Nelaton's  line  {i.e.,  an  imaginary  line 
drawn  from  the  anterior  superior  spine  of 
the  ilium  to  the  most  prominent  part  of 
the  ischial  tuberosity^. 

(5)  The  limb  is  shortened. 

(6)  There  is  often  considerable  injury  to 
muscles. 

(7)  The  great  sciatic  nerve  may  be  com- 
pressed. 

Treatment. — An  anaesthetic  is  required.  The  patient 
is  placed  on  his  back  on  a  mattress  on  the  floor;  an 
assistant  fixes  the  pelvis.  The  surgeon  first  flexes  the 
leg  and  the  thigh,  the  thigh  being  still  adducted.  This 
relaxes  the  Y-shaped  ligament.  The  limb  is  then 
steadily  rotated  out  and  abducted  (the  two  movements 
being  carried  out  simultaneously),  then  circumducted 
outwards,  and  fully  extended  so  as  to  bring  the  limb 
parallel  with  its  fellow. 

Anterior  Dislocations — 

Signs. — Obturator  variety  : — 

(i)  The  limb  is  flexed,  everted  and  slightly 
abducted. 

(2)  The  head  of  the  femur  is  felt  in  the 
perinccuiu. 

(3)  The  great  trochanter  is  less  prominent 
than  normal. 

(4)  The  limb  is  lengthened. 

(5)  Pain  from  pressure  on  the  obturator 
nerve  may  be  present. 


150  SURGERY    FOR    DENTAL    STUDENTS 

Pubic  variety: — 

(i)  The  limb  is  flexed,    everted  and  mark- 
edly abducted. 

(2)  The  head  of  the  femur  is  felt  close  to 
the  anterior  inferior  spine. 

(3)  The  great  trochanter  is  less  prominent 
than  normal. 

(4)  The  limb  is  shortened. 

(5)  The  anterior   crural  nerve   and  femoral 
vessels  may  be  injured. 

The  Treatment  of  anterior  dislocations  is  similar  to 
that  described  when  dealing  with  the  posterior  variety, 
but  the  movements  differ.  The  first  movement  of 
flexion  is  carried  out  with  the  limb  abducted;  the  limb 
is  then  rotated  inwards,  circumducted  inwards,  and  then 
extended. 

After  any  variety  of  dislocation  of  the  hip-joint  has 
been  reduced,  the  patient  should  be  kept  in  bed  with 
the  injured  leg  fixed  to  the  sound  one  with  a  bandage 
for  at  least  a  week.  Very  careful  massage  and  gentle 
passive  movements  may  then  be  commenced.  No 
active  movements  should  be  permitted  for  a  period 
varying  from  three  weeks  to  a  month. 

The  Patella  may  be  dislocated  outzuards  or  inwards; 
the  former  is  the  most  common  displacement.  It  may 
be  due  to  direct  violence  when  the  limb  is  in  a  position 
of  extension;  or  to  muscular  action  especially  in  cases 
of  genu  valgum  (knock-knee).  The  diagnosis  is  not 
difficult.  The  bone  is  easily  felt  in  its  abnormal  posi- 
tion, while  the  intercondvlar  notch  of  the  femur  can  be 
felt. 

Treatment. — The  thigh  should  be  flexed,  and  the  leg 
•extended,  when  it  will  usually  be  a  simple  matter  to 
manipulate  the  bone  back  to  place. 

Knee-joint. —  Dislocations  of  the  knee-joint  are 
rare.  The  injury  generally  follows  considerable 
violence,  and  there  is  often  great  laceration  of  the  soft 
parts.  Dislocation  of  the  lower  end  of  the  femur  for- 
wards  is  tlie  most  common  variety. 

Tt  should  be  reduced  by  means  of  traction  and 
manipulation;  operative  interference  is  required  if  the 
dislocation  is  compound  or  if  the  popliteal  vessels  are 
torn.  The  after-treatment  is  often  tedious  and  diflficult 
owing  to  the  synovitis  which  commonly  supervenes. 


INJURIES      OF     JOINTS  I5I 

Internal  Derangement  of  the  Knee-joint. — Under 
this  somewhat  vague  term  are  included  a  number  of 
injuries  involving  the  semilunar  cartilages  or  the  crucial 
ligaments. 

Perhaps  the  most  common  variety  is  a  dislocation  or 
laceration  of  the  internal  semilunar  cartilage.  It  fre- 
quently occurs  when  a  man  makes  a  sudden  turn  of  his 
body  while  the  leg  is  fixed,  e.g.,  in  playing  rather  late 
at  a  ball  a  little  wide  on  the  leg  side  to  turn  it  towards 
fine  long-leg".  The  injury  is  characterized  by  sudden 
violent  pain,  while  the  knee  is  fixed  in  a  semi-flexed 
position. 

The  immediate  treatment  is  to  flex  the  leg  fully, 
rotate  in  and  quickly  extend  it. 

The  after-treatment  is  very  complicated,  and  need 
not  be  dealt  with  here. 

The  Ankle-joint  may  be  dislocated  in  any  direction. 
This  injury  is  often  associated  with  a  fracture  near 
the  lower  end  of  the  fibula,  and  sometimes  of  the  tibia 
also. 

The  diagnosis  may  be  difficult  without  the  aid  of 
X-rays. 


CHAPTER    XIX. 
DISEASES    OF    JOINTS. 

In  this  chapter  it  is  proposed  to  deal  quite  briefly 
with  the  more  important  pathological  conditions  of  the 
joints  generally,  and  then  to  apply  these  general  prin- 
ciples to  the  study  of  the  diseases  which  affect  the 
temporomaxillary  articulation . 

The  inflammatory  affections  of  joints  are  classified 
according  to  the  position  of  the  lesion  into  Synovitis 
(inflammation  of  the  synovial  membrane)  and  Arthritis 
(inflammation  of  the  articular  surfaces).  From  what 
he  has  read  in  previous  chapters  in  this  book,  the 
student  will  no  doubt  guess  that  no  real  hard-and-fast 
line  can  be  drawn  between  these  two  classes  of  disease; 
the  division  is  purely  made  for  the  sake  of  convenience 
in  description.  Synovitis  and  arthritis  may  each  be  of 
two  varieties :  acute  and  chronic. 

Acute  Synovitis  may  result  from  a  variety  of  causes, 

both  local  and  general,  of  which  the  following  are  the 

most  important:    local   causes,   injury  or  exposure  to 

cold;   general   causes,   rheumatism,    gout,    and   gonor- 

^      rhoea. 

The  disease  is  characterized  by  rapid  effusion  of  fluid 
into  the  joint,  accompanied  by  the  cardinal  signs  of 
acute  inflammation,  vi;:.,  considerable  pain,  swelling, 
heat,  and  occasionally  redness  of  the  skin.  The  limb 
is,  as  a  rule,  instinctively  kept  in  the  position  which 
allows  most  room  in  the  joint  cavity. 

A  correct  diagnosis  of  the  cause  is  important  from 
the  point  of  view  of  treatment.  Much  may  be  learnt 
from  the  history.  A  liistory  of  local  trauma  or  of 
hereditary  gouty  tendenc}'  are  suggestive  points.  The 
I)articular  joint  affected  is  also  an  aid  to  diagnosis, 
l-'or  example,  an  acute  inflammation  affecting  the  great 
toe  will  suggest  the  diagnosis  of  gout.  In  a  typical 
acute  attack  of  gout  the  skin  has  a  dark  red,  mottled, 
shiny,  cedematous  appearance  which  is  very  character- 
istic. 


DISEASES     OF    JOINTS  153 

A  well-known  surgeon  vised,  in  teaching,  to  make 
the  dogmatic  statement  that  cui  acute  inflammatory 
affection  of  a  single  joint  in  a  young  man,  where  there 
is  no  history  of  injury  ,  is  Gonorrheal  arthritis.  And 
though  perhaps  a  little  sweeping,  the  statement  will 
probably  be  found  to  be  correct  in  an  overwhelming 
majority  of  cases,  and  serves  to  enforce  the  import- 
ance of  never  forgetting  to  think  of  gonorrhoea,  in 
women  as  well  as  men.  For  obvious  reasons  the 
patient  will  rarely  volunteer  the  information. 

Another  sweeping  statement  in  connection  with  acute 
synovitis  which  may  be  of  value  is  the  following :  — 

IVJicn  you  feel  inclined  to  diagnose  acute  rheu- 
matism in  a  child,  don't.  Acute  rheumatism  is  very 
rare  in  children,  while  the  much  commoner  acute 
osteomyelitis  often  gives  a  very  similar  clinical  picture. 

Treatment. — In  gonorrhoeal  synovitis,  the  important 
point  is  to  treat  the  gonorrhoea  {q.v.).  Local  treat- 
ment consists  in  rest  and  the  application  of  glycerine 
of  belladonna  fomentations. 

In  gout,  absolute  rest  is  essential.  An  alkaline  lotion 
may  be  applied  locally  {e.g.,  a  saturated  solution  of 
sod.  bicarb.),  colchicum,  lithia,  or  sodium  salicylate  may 
be  given  internally,  either  separately  or  in  combination. 
Some  patients  seem  to  react  better  to  one  of  these 
drugs,  others  to  another.  Alcohol  should  certainly  be 
forbidden  during  the  acute  attack.  Into  the  much 
debated  question  of  the  amount  and  kind  of  alcohol 
to  be  allowed  after  the  attack  has  passed  it  is  quite  un- 
necessary tor  us  to  wander. 

In  traumatic  cases  rest  and  belladonna  fomentations 
will  be  required  in  the  acute  stag"e,  while  counter- 
irritation,  by  means  of  Scott's  dressing,  may  be  used 
later  on.  Massag'e  and  passive  movements  will  be 
necessary  to  avoid  subsequent  adhesions  in  the  joint. 
Where  the  affection  becomes  chronic,  owing,  for  in- 
stance, to  the  presence  of  a  loose  piece  of  bone  frac- 
tured i'l  the  injury,  a  torn  piece  of  synovial  membrane, 
or  in  the  case  of  the  knee-joint,  some  injury  to  a  semi- 
lunar cartilage,  operative  treatment  is  usually  required. 

Acute  Infective  Arthritis  is  a  much  more  severe  con- 
dition, in  which  all  the  structures  of  the  joint  are 
involved.  Infection  may  reach  the  joint  from  without 
by  means   of  a  wound,  or  from  zvithin  by  extension 


154  SURGERY    FOR    DENTAL    STUDENTS 

from  acute  bone  disease,  or  as  part  of  a  general 
pyaemia.  In  either  case  acute  suppuration  occurs  in 
the  joint. 

Trcatnioit. — Immediate  operative  interference  is  re- 
quired to  evacuate  the  pus  and  wash  out  the  joint.  In 
ver}'  severe  cases  amputj^tion  may  be  indicated. 

GonorrhcEal  Arthritis  is  merely  a  further  stage  of  the 
condition  described  as  g'onorrhoeal  synovitis,  the  articu- 
lar surfaces  being  affected  as  well  as  the  synovial  mem- 
^  brane.  The  condition  should  be  dealt  with  on  the 
same  lines  as  for  gonorrhoeal  synovitis. 

Acute  Arthritis  may  occur  as  a  complication  of  one 
of  the  acute  specific  fevers,  notably  typhoid  fever.  In 
these  cases  a  large  amount  of  fluid  effusion  is  usually 
present. 

Treatment  by  rest  and  Scott's  dressing  will  usually  be 
sufficient.  If  a  very  large  quantity  of  fluid  is  present, 
the  joint  should  be  aspirated  with  aseptic  pi*ecautions. 

Simple  Chronic  Synovitis  occurs  either  as  the  result 
of  an  acute  attack,  or  as  following  some  injury  or  local 
irritation,  the  severity  of  which  is  insufficient  to  deter- 
mine an  acute  attack. 

Two  types  are  described,  according  as  effusion  of 
fluid  or  thickening  of  the  synovial  membrane  is  the 
more  prominent  feature. 

Treatment. — The  joint  should  be  dressed  with  Scott's 
dressing,  and  then  strapping  should  be  applied;  com- 
plete rest  of  the  joint  must  be  secured.  Where  the 
fluid  effusion  is  large  and  does  not  absorb,  aseptic 
aspiration  of  the  joint  may  be  performed.  If  there  is 
considerable  synovial  thickening,  the  administration  of 
iodolysin  by  the  mouth  (5SS  three  times  a  day)  may 
assist  in  its  absorption. 

In  some  cases,  other  structures  in  the  joint  besides 
the  synovial  membrane  are  affected;  these  cases  should 
strictly  be  called  chronic  arthritis,  but  the  alteration  in 
name  does  not  involve  any  alteration  in  treatment. 

Tuberculous  Arthritis  is  a  disease  common  in 
children  and  young  adults.  Those  conditions  pre- 
viously mentioned  as  predisposing  causes  of  tuber- 
culosis generally  (see  Chapter  XII),  and  which  may  be 
roughly  described  as  faulty  hygiene,  have  a  similar 
action  in  preparing  the  way  for  tuberculous  arthritis. 

The   actual   attack   of  the   disease   often  dates   from 


DISEASES     OF    JOINTS  l5o 

some  trivial  injury  to  the  joint  concerned.  In  children, 
the  liip-jonit  is  by  far  the  most  frequently  affected;  in 
adults,  the  knee-joint  perhaps  takes  hrst  place.  The 
infection  may  start  in  various  places,  vk.,  the  synovial 
membrane,  the  periosteum,  the  bone,  or  a  bursa  con- 
nected with  the  joint. 

The  onset  of  the  disease  is  usually  very  insidious, 
commencing-  with  slight  impairment  of  movement  in 
the  joint  which  the  patient  scarcely  notices,  but  is 
detected  by  the  surgeon  as  slight  rigidity  in  the  joint. 
This  may  be  accompanied  by  slight,  dull,  aching  pain 
and  a  feeling-  of  "  wxight  "  in  the  part.  On  examina- 
tion in  the  early  stages  there  may  be  little  to  be  made 
out.  The  effusion  of  fluid  is  commonly  very  small  in 
amount;  dehnite  thickening  of  the  synovial  membrane, 
or  of  the  articular  ends  of  the  bones,  can  in  most  cases 
be  discovered;  the  affected  joint  is  usually  definitely 
hotter  than  the  corresponding  joint  on  the  other  side. 
It  is  essential  that  the  opposite  joint  should  be 
examined  at  the  same  time  as  the  diseased  one,  in 
order  that  any  slight  differences  may  be  detected.  In 
the  later  stages  these  signs  are  increased;  the  synovial 
thickening,  the  rigidity,  the  pain,  and  in  some  cases 
the  effusion.  Some  muscular  wasting  may  be  present, 
as  a  result  of  disuse  due  to  the  pain  caused  by  move- 
ment of  the  joint.  The  general  health  is  usually 
affected,  the  patient  being  thin  and  pale,  with  a  bad 
appetite,  and  often  running  an  irregular  temperature. 
"  Starting  pains  "  at  night  are  a  very  unpleasant 
feature  of  the  malady;  when  the  patient  is  awake  the 
muscles  are  constantly  in  action,  holding  the  joint  rigid 
and  so,  as  far  as  possible,  avoiding  pain;  when  the 
patient  is  asleep  the  muscles  gradually  relax,  until  a 
movement  occurs  in  the  joint,  and  a  sudden  "  starting- 
pain  ''  results.  The  so-called  mcloji-sccd  bodies  may  be 
formed.  If  left  untreated,  suppuration  occurs  in  the 
joint,  accompanied  by  the  formation  of  sinuses. 

TJie  diagjiosis  is  often  very  difficult,  especially  in  the 
■early  stages.  In  every  chronic  arthritis,  even  if  there 
be  a  history  of  injury,  always  suspect  tubercle.  In  a 
simple  chronic  arthritis  it  may  be  quite  impossible  to 
exclude  tuberculosis  with  any  degTee  of  certainty,  but 
a  non-tubercular  arthritis  will  usually  clear  up  under 
treatment,  whereas  a  tubercular  affection  will  prove  far 


156  SURGERY   FOR    DENTAL    STUDENTS 

more  obstinate.  A  neoplasm  of  the  end  of  the  bone 
may  simulate  tuberculous  arthritis;  but  the  latter  is  far 
the  more  common  affection.  A  skiagram  will  be  of 
great  value  in  many  cases,  while  assistance  may  be 
obtained  from  such  tests  as  the  opsonic  index,  Von 
rirquet  s  test,  Sic.""' 

Treatment. — General  hygienic  treatment  as  laid  down 
in  Chapter  XII  should  be  instituted.  Local  treatment 
consists  of  absolute  rest  and  the  application  of  Scott's 
dressing.  Extension  of  the  limb  by  means  of  some 
mechanical  device,  such  as  a  weight  and  pulley,  should 
be  applied,  especially  when  the  knee-joint  is  affected,  in 
order  to  keep  the  two  articular  surfaces  apart. 

The  injection  of  sterilized  iodoform  emulsion  is  a 
form  of  treatment  about  which  very  varied  opinions  are 
held  by  different  authorities.  It  seems  to  be  of  most 
value  when  there  is  much  effusion  of  fluid.  A  10  per 
cent,  solution  of  iodoform  is  used,  the  amount  varying 
according  to  the  joint  involved,  and  the  age  of  the 
patient.     About  ^i  is  an  average  quantity  in  an  adult. 

Bier's  treatment  is  often  of  great  value.  A  bandage 
is  applied  to  the  limb,  sufficiently  firmly  to  impede  the 
venous  circulation  while  not  interfering  with  the  flow  in 
the  arteries,  thus  causing  a  passive  hypercemia  in  the 
affected  part.  The  bandage  is,  of  course,  applied  on 
the  proximal  side  of  the  diseased  joint. 

The  course  of  the  disease  is  very  slow  even  in  favour- 
able cases,  and  the  prognosis  should  always  be  of  a 
p'uarded  nature. 

T  •  •  •  r  •  'J 

In  certain  cases,  operative  interference  is  required. 
Where  suppuration  has  occurred,  the  joint  should 
always  be  opened  at  once.  In  cases  where  no  suppura- 
tion has  occurred,  the  question  of  operation  is  very 
difficult  to  decide;  some  surgeons  will  advise  operation 
much  more  frequently  than  others. 

Syphilitic  Arthritis.— fn  the  secondary  stage,  slight 
synovitis  may  occur,  giving  rise  to  slight  stiffness  and 
effusion  of  fluid.  No  pain  is  present  as  a  rule.  Anti- 
syphilitic  remedies  are  indicated.  In  the  tertiary  stage, 
a  gummatous  infiltration  of  the  synovial  membrane  may 
occur.  The  affection  is  painless,  and  the  quantity  of 
fluid  in  the  joint  commonly  very  large;  the  condition  is 

*  For  details  of  these  te'^ts  the  student  should  refer  to  a  larger  text- 
book. 


DISEASES     OF    JOINTS  157 

often  bilateral.  These  three  points  may  serve  to 
differentiate  between  this  condition  and  tubercle,  but 
the  diagnosis  is  often  difficult. 

Ordinary  antisyphilitic  treatment  should  be  adminis- 
tered. 

Osteoarthritis  is  a  condition,  or  perhaps  a  group  of 
allied  conditions,  known  by  a  variety  of  names,  of 
which  Rheumatoid  arthritis,  Arthritis  deformans  and 
Rheumatic  gout  are  examples.  Different  authorities 
use  these  terms  in  somewhat  different  senses;  but  for 
the  purpose  of  this  book  it  will  be  sufficient  to  group  all 
the  varieties  under  the  one  heading,  Osteoarthritis. 

Osteoarthritis  is  a  very  chronic  disease.  Various 
theories  as  to  its  etiology  have  been  promulgated, 
and  many  discarded;  current  opinion  seems  to  favour 
the  view  that  the  condition  is  infective  in  origin.  The 
infection  may  reach  the  joint  through  the  blood-stream 
from  a  septic  focus  anywhere  in  the  body.  Pyorrhoea 
alveolaris  and  oral  sepsis  of  any  kind  are  examples  of 
septic  foci  from  which  osteoarthritis  may  originate. 
The  importance  of  these  septic  conditions  of  the  mouth 
and  teeth  in  relation  to  osteoarthritis  is  demanding  ever 
increasing  attention  at  the  present  time,  and  it  is  on 
this  account  that  the  disease  is  of  such  importance  to 
the  dental  specialist,  as  his  aid  is  frequently  invoked 
both  in  the  diagnosis  of  the  cause  and  in  the  treatment 
of  the  malady. 

Tw^o  types  of  the  disease  present  themselves,  viz., 
the  monarticular  and  the  polyarticular  variety. 

The  monarticvilar  variety,  as  its  name  applies,  affects 
single  joints,  the  large  joints  being  most  frequently 
attacked.  The  course  of  the  disease  is  very  slow.  It 
commences  with  pain  and  stiffness  in  the  joint.  In 
the  early  stages  this  pain  and  stiffness  makes  its  appear- 
ance after  the  joint  has  been  at  rest  for  some  time  (e.g., 
on  waking  up  in  the  morning),  and  passes  off  as  the 
joint  is  exercised.  As  the  disease  progresses,  the 
rigidity  and  pain  increase,  while  crackling  noises  can 
be  detected  in  the  joint  when  it  is  moved.  Enlarge- 
ment of  the  ends  of  the  bones  in  the  joint  takes  place. 
The  cartilage  covering  the  articular  ends  of  the  bones 
proliferates,  and  projections  are  formed  which  gradu- 
ally undergo  ossification;  the  capsular  ligament  mav 
also  become  ossified  at  its  attachment  to  the  bone,  this 


158  SURGERY  FOR    DENTAL    STUDENTS 

phenomenon  being  generally  described  as  lipping  of  the 
ends  of  the  bones.  At  the  same  time  that  this  prolifera- 
tion of  cartilage  and  its  subsequent  ossification  is  taking 
place,  the  opposing  articular  surfaces  in  the  joint 
become  worn  away  at  the  points  where  pressure  occurs, 
the  bone  becoming  rarefied  and  atrophied.  These  pro- 
cesses result  in  considerable  alteration  in  the  shape 
and  size  of  the  bones  entering  into  the  formation  of 
the  joint.  Movement  in  the  joint  becomes  increasingly 
difticult,  and,  as  a  result,  considerable  muscular  wasting 
occurs  from  disuse. 

In  the  polyarticular  variety,  many  joints  are  involved, 
the  smaller  joints  being  chiefly  affected.  The  disease 
may  begin  in  one  joint,  and  gradually  spread  to  others, 
but  in  most  cases,  several  joints  are  attacked  simul- 
taneously. The  pathological  and  clinical  features  are 
similar  to  those  described  above. 

In  the  diagnosis  of  this  condition.  X-rays  play  an 
important  part,  the  lipping"  of  the  edges  of  the  articular 
surfaces  combined  witli  rarefaction  in  the  centre  being 
as  a  rule  well  shewn. 

The  treatment  of  osteoarthritis  is  unsatisfactory,  and 
the  prognosis  consequently  unfavourable.  The  patient 
should  live  in  as  dry  and  warm  a  climate  as  possible. 
An  ordinary  diet  may  be  allowed,  plenty  of  fats  being 
included  in  it.  Any  septic  focus  that  is  discovered 
must  be  treated,  and  any  roots  or  doubtful  teeth 
extracted.  Drugs  are  not  of  any  great  value.  Cod 
liver  oil  and  syrupus  ferri  phosph.  may  be  given,  while 
the  bowels  should  be  kept  regular  by  means  of  saline 
purges,  if  required.  Sodium  iodide  has  been  given 
with  success. 

As  regards  local  treatment,  the  joint  should  not  be 
used  too  much,  l)ut,  on  the  other  hand,  it  must  not  be 
kept  at  rest;  moderate  exercise  should  be  insisted  upon, 
though  this  may  be  difficult  on  account  of  the  pain. 

Hot-air  baths  followed  by  massage,  electric  baths 
and  ionization  may  do  good. 

Hcernophilia. — In  persons  suffering  from  this  disease 
a  trivial  injury  may  result  in  a  sudden  effusion  of  blood 
into  the  joint.  When  this  occurs  the  joint  must  be 
kept  absolutelv  at  rest,  while  ice-bags  are  applied  to 
the  part.  The  general  treatment  of  the  malady  is 
given  on  page  104. 


DISEASES     OF    JOINTS  159 

Neuropathic  affections  of  joints  (Charcot's  disease) 
occur  during  the  course  of  certain  diseases  of  the 
central  nervous  system,  notably  tabes  dorsalis  and 
syringomyelia.  Two  varieties  are  described:  — 
'  In  the  atrophic  variety,  rapid  erosion  of  the  cartilage 
and  bone  takes  place,  associated  usually  with  the  rapid 
effusion  of  a  large  quantity  of  fluid  into  the  joint. 

In  the  hypertrophic  variety,  the  fluid  effusion  is 
accompanied  by  hypertrophy  of  the  bone  and  other 
structures  in  the  joint.  In  both  these  types,  no  pain 
is  experienced. 

Diagnosis. — The  absence  of  pain,  the  absence  of  the 
characteristic  lipping  of  the  cartilages,  and  the  large 
quantity  of  fluid  effused,  combined  with  the  physical 
signs  of  the  underlying  nervous  disease,  will  suffice  to 
differentiate  between  Charcot's  disease  and  osteo- 
arthritis, the  condition  with  which  it  is  most  likely  to 
be  confused. 

Treatment. — This  is  merely  directed  towards  the 
relief  of  symptoms.  Very  large  effusions  may  require 
aspiration.  In  the  atrophic  variety,  increased  mobility 
of  the  joint  is  often  tiresome  to  the  patient;  in  such  a 
case  some  relief  may  be  obtained  from  the  use  of  a 
suitable  splint. 

Diseases  of  the  Temporomaxillary  Articulation — 

Acute  Pheumatism  sometimes  occurs  in  this  joint, 
giving  rise  to  acute  pain,  slight  effusion  of  fluid,  and 
sometimes  some  fcA'er. 

Treatment. — The  administration  of  sodium  salicylate 
gr.  XV  three  times  a  day  is  usually  sufficient  to  deal 
with  the  condition.  Subsequent  adhesions  and  conse- 
quent ankylosis  of  the  jaw  (q.v.)  may  result. 

Gonorrhoea!  Arthritis  is  rare  in  this  joint.  It 
should  be  treated  as  described  imder  gonorrhoea! 
arthritis  generall}'. 

Simple  Traumatic  Synovitis  from  exposure  to  cold 
or  injury  is  rare. 

Infective  Arthritis  is  fairly  common.  It  may  arise 
from  a  penetrating  wound;  from  extension  from  a  local 
septic  focus,  e.g.,  disease  of  the  low^er  jaw.  dental 
disease,  middle  ear  disease,  osteomyelitis  of  the  tem- 
poral bone,  &:c. ;  or  as  part  of  a  general  pyaemia.  In 
cases  arising  from  middle  ear  disease,  the  infection 
spreads  through  the  Glaserian  fissure. 


l60  SURGERY   FOR    DENTAL    STUDENTS 

The  treatment  is  the  same  as  for  infective  arthritis 
elsewhere.  There  is  a  great  tendency  to  ankylosis 
{q.v.). 

Osteoarthrit's  is  fairly  common,  and  is  very  prone  to 
result  in  ankylosis. 

Tubercle,  Syphilis,  and  Charcot's  disease  are  very 
rare  in  this  joint. 

Ankylosis  of  the  Jaw. — Any  of  these  pathological 
conditions  affecting  the  temporomaxillary  articulation 
may  result  in  union  of  the  two  bones  which  enter  into 
the  formation  of  the  joint.  This  union  is  usually 
fibrous,  but  may  be  bony.  The  condition  is  known  as 
true  ankylosis. 

The  jaw  may  also  be  fixed  by  conditions  involving 
the  surrounding  soft  parts,  e.g.,  scars  after  burns  or 
other  injuries,  or  even  actual  formation  of  bone  in  the 
muscles  {myositis  ossificans).  Fixation  of  the  jaw  in 
this  way  is  known  as  false  ankylosis.  The  temporo- 
maxillary articulation  is  very  prone  to  become  anky- 
losed,  hence  the  manifest  importance  of  beginning 
passive  movements,  &c.,  as  early  as  possible  when 
treating  disease  of  this  joint.  All  adhesions  should  be 
broken  down  under  an  anaesthetic  as  soon  as  they 
form. 

If  actual  fibrous  ankylosis  has  occurred,  an  attempt 
may  be  made  to  break  down  the  union  by  force  under 
an  anaesthetic,  a  gag  being  subsequently  inserted  to 
avoid  reunion.  In  spite  of  this  precaution,  there  may 
still  be  recurrence  of  the  ankylosis.  The  condyle  of 
the  lower  jaw  should  then  be  excised. 

Spasmodic  Closure  of  the  Jaws  :  Trismus. — This 
is  due  to  spasmodic  contraction  of  the  masseters  result- 
ing from  hysteria  or  from  some  local  focus  of  irrita- 
tion. 

The  chief  local  irritative  causes  of  trismus  are  :  ■ — 

(i)  A  malplaced,  malerupting  lower  wisdom  tooth, 
especially  when  butting  into  the  second  molar,  and 
exposing  its  nerve. 

(2)  Any  condition  which  may  cause  a  lower  wisdom 
tooth  to  press  on  the  inferior  dental  nerve,  e.g.,  an 
abscess  at  the  root  of  the  tooth.  It  should  be  noted 
that  the  inferior  dental  nerve  is  normally  closer  to  the 
third  than  to  the  second  molar;  it  often  grooves,  and 
sometimes  even  perforates  the  roots  of  the  third  molar, 


DISEASES     OF    JOINTS  l6l 

and  is  consequently  very  liable  to  be  affected  by  disease 
of  this  tooth. 

(3)  Disease  of  the  neighbouring  bone  or  glands. 

(4)  Odontomes. 

The  condition  has  been  mentioned  in  discussing  the 
differential  diagnosis  of  tetanus. 

Treatment. — First  remove  the  cause  of  irritation ; 
when  this  has  been  done,  massage  of  the  masseter  and 
passive  movements  of  the  jaw  should  be  employed. 
Even  though  the  jaw  be  firmly  closed,  it  is  quite  pos- 
sible to  extract  the  lower  wisdom  tooth  with  a  curved 
elevator,   without  opening  the  mouth. 


11 


CHAPTER   XX. 
SPECIAL   INJURIES    OF    FACE    AND    NECK. 

Scalp.  —An  injury  to  the  scalp,  which  causes  effusion 
of  blood,  but  does  not  break  the  skin,  results  in  a 
hx^natoTna  or  blood  tumour.  A  hsematoma  may  be 
situated  in  one  of  three  positions:  — 

(i)  Between  the  skin  and  the  occipitofrontalis  muscle 
or  aponeurosis. 

(2)  Between  the  occipitofrontalis  and  the  pericranium. 

(3)  Between  the  pericranium  and  the  bone. 

In  the  first  variety,  the  effusion  of  blood  is,  limited  in 
extent  by  the  density  of  the  subcutaneous  tissue,  and 
does  not  spread  far.  If  treated  like  an  ordinary  bruise, 
with  lotio  plumbi  and  ice  it  soon  disappears. 

In  the  second  variety,  the  effusion  is  only  limited  by 
the  attachments  of  the  occipitofrontalis  muscle.  The 
blood  therefore  may,  and  often  does,  spread  over  this 
whole  area.  The  possibility  of  a  fracture  of  the  skull 
being  present  in  addition  to  the  hsematoma  must  not 
be  overlooked. 

Treatment  should  include  the  application  of  an  ice- 
bag  to  limit  the  effusion;  if  the  blood  is  slow  in  absorb- 
ing, an  elastic  bandage  may  be  applied. 

The  third  variety  of  hsematoma  occurs  most  usually 
as  the  result  of  an  injury  during  delivery.  It  is  very 
likely  to  be  mistaken  for  a  depressed  fracture  of  the 
skull,  on  account  of  the  hard  ridge  of  coagulated  blood 
surrounding  a  softish  centre  which  it  presents.  Careful 
examination  will  show  that  there  is  no  real  depression 
of  the  bone. 

It  should  be  treated  in  the  same  way  as  the  other 
varieties. 

Injuries  of  the  scalp  in  which  the  skin  is  broken  do 
not  differ  materially  from  wounds  elsewhere;  the 
danger  of  sepsis  is  somewhat  increased,  if  the  wound 
penetrates  below  the  epicranial  aponeurosis.  The 
haemorrhage  caused  by  such  an  injury  is  usually 
successfully  treated  by  pressure  applied  by  means  of  a 


SPECIAL    INJURIES    OF    FACE   AND    NECK  163 

dressing  and  bandage,  stitches  being  inserted  if 
required.  If  either  the  temporal  or  occipital  arteries 
be  wounded  the  artery  should  be  completely  cut 
through  if  the  wound  be  only  partial,  and  the  bleeding 
end  seized  in  artery  forceps  and  twisted.  If  this  fails 
to  stop  the  haemorrhage  a  ligature  should  be  applied. 

Great  care  should  be  taken  to  avoid  any  infection  of 
the  wound.  The  neighbourhood  of  the  injury  should 
be  carefully  shaved,  purified,  and  dressed  aseptically. 

If  infection  occurs  in  spite  of  these  precautions,  a 
severe  cellulitis  may  result,  which  is  very  liable  to 
spread  to  the  meninges.  Free  incisions  should  be 
made  at  once,  the  pus  evacuated,  and  fomentations 
applied.  Surgical  emphysema — that  is  to  say,  an 
accumulation  of  air  beneath  the  skin — may  arise  from 
the  involvement  of  one  of  the  air  sinuses  of  the  skull 
in  a  fracture.  Fractures  of  the  skull  are  dealt  with  in 
Chapter  XVI. 

Wounds  of  the  neck  are  of  special  interest  on  account 
of  the  important  structures  liable  to  injury.  Injuries 
of  the  neck  are  more  commonly  intentional  than 
accidental.  An  attempt  to  commit  suicide  by  cutting 
the  throat  rarely  results  in  injury  to  the  large  vessels, 
these  structures  being  more  difficult  to  wound  than 
mig'ht  be  supposed.  If  a  large  vessel,  such  as  the 
carotid  artery,  is  wounded,  the  haemorrhage  is,  as  a 
rule,  so  severe  that  death  ensues  before  surgical  aid 
can  be  obtained. 

In  most  cases,  however,  the  cut  passes  between  the 
hyoid  bone  and  the  thyroid  cartilage,  the  resulting 
haemorrhage  being  mostly  venous.  The  arteries  most 
frequently  injured  are  the  superior  thyroid  and  the 
lingual.  These  arteries  may  require  to  be  ligatured, 
but  the  venous  haemorrhage  will  usually  cease  spon- 
taneously from  the  contact  with  cold  air.  The  wound 
should  be  treated  on  general  lines.  {See  Chapters  VI 
and  VII.) 

The  following  are  the  more  important  complications 
which  may  occur  :  — 

The  base  of  the  epiglottis  mav  be  divided,  and  cause 
obstruction  to  respiration  by  falling"  backwards. 

If  the  wound  is  lower  down,  the  larynx  or  trachea 
may  be  injured;  respiration  may  again  be  impeded  by 
the  entrance  of  blood  into  the  air  passages. 


164  SURGERY  FOR    DENTAL    STUDENTS 

The  pJiarynx  or  oesophagus  may  also  be  wounded; 
an  injury  of  this  nature  will  necessitate  great  care  in 
the  subsequent  feeding  of  the  patient.  At  first,  it  will 
be  wise  to  give  nourishment  per  rectum,  but  patients 
suffering  from  cut-throat,  especially  if  the  injury  be 
attempted  suicide,  are  usually  in  a  condition  of  severe 
shock,  and  require  plenty  of  nourishment  afterwards. 
As  soon  as  possible,  therefore,  a  stomach  tube  should 
be  passed  in  order  that  food  may  be  given  by  the 
mouth,  extreme  care  being"  used  in  the  operation. 

Later  complications  include  septic  pneumonia  from 
the  inhalation  of  blood  and  septic  matter  through  the 
wound;  and  cellulitis  of  the  neck;  both  of  which  con- 
ditions are  very  grave. 

Treatment. — (1)  If  any  grave  obstruction  to  respira- 
tion be  present,  it  must  be  dealt  with  at  once,  at  least 
temporarily.  It  may  be  necessary  to  use  a  tracheotomy 
tube,  inserted  either  through  the  original  wound,  or 
through  a  separate  incision  made  on  purpose.  The 
choice  of  method  will  depend  upon  the  particular  cir- 
cumstances obtaining  in  each  individual  case. 

(2)  Arrest  the  hcemorrhage. 

(3)  Treat  the  shock  and  collapse,  which  are  often 
severe.  In  simple  cases,  where  neither  air  passages 
nor  alimentarv  tract  are  involved,  the  Durification  of 
the  wound  and  the  application  of  an  aseptic  or  anti- 
septic dressing  will  complete  the  treatment.  When 
these  important  structures  are  wounded,  operative 
measures,  the  details  of  which  vary  with  each  individual 
case,  will  be  required. 

Foreign  Bodies  in  the  Air  Passages.— A  large 
foreign  body,  very  frequently  a  bolus  of  food,  will 
lodge  at  the  entrance  to  the  larynx,  and  may  com- 
pletelv  block  the  opening,  preventing  the  entrance  of 
air.     The  patient  becomes  cyanosed  from  asphvxia. 

Treatment  if  it  is  to  be  of  any  value  must  be  imme- 
diate. First  make  an  attempt  to  reach  and  dislodge 
the  foreign  body  with  the  fmger.  Do  not  waste  valu- 
able time  over  three  or  four  attempts.  You  have  onlv 
a  very  short  time  in  which  to  save  a  human  life,  and  if 
you  do  not  at  once  succeed  in  dislodging  the  foreig^n 
body  with  your  finger,  laryngotomy  must  be  performed. 
Place  the  patient  flat  on  his  back  on  the  floor.  Run 
your  finger  rapidly  upwards  along  the  trachea  in  the 


SPECIAL    INJURIES    OF    FACE   AND    NECK  165 

middle  line  of  the  neck.  The  first  prominence  which  is 
felt  is  the  cricoid  cartilage.  Just  above  this  is  a  larger 
prominence,  the  thyroid  cartilage  or  "Adam's  apple." 
The  larynx  is  to  be  opened  by  piercing  the  crico- 
thyroid membrane,  that  is  to  say,  the  space  in  between 
the  two  prominences  mentioned.  If  no  surgical  knife 
is  at  hand,  use  the  cleanest  and  sharpest  pocket  knife 
available.  Hold  the  knife  in  such  a  way  that  one  finger 
rests  on  the  fiat  of  the  knife,  leaving  not  more  than  a 
quarter  of  an  inch  of  the  blade  bare  beyond  the  tip  of 
the  finger.  This  is  to  prevent  the  knife  passing  right 
through  the  posterior  laryngeal  wall,  and  wounding  the 
structures  lying  behind.  Plunge  the  knife,  transversely 
straight  into  the  larynx,  and  turn  the  blade  through 
a  right  angle.  Don't  worry  about  the  haemorrhage. 
The  veins,  engorged  w^ith  blood  by  the  asphyxia,  will 
bleed  profusely  at  first;  but  as  soon  as  the  larynx  is 
opened,  and  the  patient  begins  to  breathe,  the  bleeding 
will  almost  stop,  and  can  be  dealt  with  later.  If  a 
laryngotomy  tube  is  at  hand  it  should  be  inserted.  If 
not,  the  wound  must  be  kept  open  by  some  other 
means.  Two  hairpins  bent  in  the  shape  of  hooks  will 
form  a  convenient  means  for  holding  the  two  sides  of 
the  wound  apart.  Artificial  respiration  may  still  be 
required  to  start  the  patient  breathing. 

Smaller  articles,  e.g.,  small  artificial  dentures,  which 
are  causing  dyspnoea,  but  do  not  completely  obstruct 
the  entrance  of  air,  may  be  picked  out  with  the  aid  of 
special  forceps  called  laryngeal  forceps.  Small  objects 
of  this  kind,  which  do  not  cause  asphyxia  by  their  own 
size,  may  do  so  by  inducing  oedema  of  the  glottis.  In 
these  cases  the  symptoms  are  not  of  such  great  urgency 
as  those  described  above.  If  the  dvspnoea  is  urgent, 
laryngotomy  or  tracheotomy  should  be  performed. 
(Tracheotomy  is  described  on  page  177.)  A  careful 
laryngeal  examination  should  then  be  made,  in  case  it 
should  be  possible  to  reach  the  object  with  forceps. 
X-rays  are  often  of  great  service  in  determining  the 
position  of  the  obstruction.  If  it  cannot  be  reached 
with  forceps  operative  measures  will  be  required  for 
its  removal.  A  very  small  object  may  pass  rig'ht  down 
into  a  bronchus,  and  escape  diagnosis  altogether.  The 
probable  consequences  of  such  a  condition  would  be 
collapse  of  the  corresponding  lung,  or  septic  bronchitis 


1 66  SURGERY  FOR    DENTAL    STUDENTS 

and  empyema.  The  right  bronchus  is  wider  and  more 
vertical  than  the  left,  and  consequently  foreign  bodies 
more  frequently  enter  the  right  bronchus. 

Foreign  Bodies  in  the  ffisophagus.  — Many  extra- 
ordinary objects  have  been  swallowed,  especially  by 
children  and  lunatics.  Under  ordinary  circumstances, 
fishbones,  coins,  marbles,  artificial  denture^,  and 
obstructive  boluses  of  food  are  among  the  most  com- 
mon foreign  bodies  which  lodge  in  the  oesophagus.  If 
the  object  is  a  piece  of  food,  and  is  capable  of  being 
pushed  on  into  the  stomach,  this  is  the  best  treatment. 
Small  articles  which  have  reached  the  stomach,  such  as 
small  coins,  will  probably  be  passed  per  rectum,  and 
should  be  left  to  do  so.  When  an  object  is  impacted 
in  the  oesophagus.  X-rays  will  give  valuable  aid  in 
determining  its  position.  Various  ingenious  instru- 
ments have  been  devised  for  removing  foreign  bodies 
from  the  oesophagus,  of  which  the  probang  and  the 
coin-catcher  are  examples.  Such  a  thing  as  a  denture, 
especially  if  armed  with  wires  and  bands,  may  be  very 
difficult  to  remove  without  damaging  the  surrounding 
tissues.  If  necessary,  operative  measures  must  be 
employed. 


CHAPTER    XXI. 

DISEASES   OF   THE   MOUTH,    LIPS,   PALATE, 
TONSILS    AND    PHARYNX. 

Catarrhal  Stomatitis,  or  catarrhal  inflammation  of 
the  buccal  mucous  membrane,  resembles  in  its  patho- 
logical features  catarrhal  inflammation  in  other  mucous 
membranes  (vide  Chapter  HI).  The  condition  may 
result  from  a  variety  of  causes,  of  which  the  following 
are  the  most  common  :  — 

(i)  Any  local  irritation,  such  as  a  roughened  tooth 
or  ill-fitting  denture;  certain  irritant  drugs,  such  as 
mercury  (vide  Mercurial  Stomatitis),  or  the  constant 
drinking  of  neat  spirits;  any  septic  condition  present 
in  the  buccal  cavity. 

(2)  Chronic  gastro-intestinal  disorders. 

(3)  The  condition  may  occur  during  the  course  of  an 
acute  specific  fever. 

(4)  Pneumococcal  infection.  This  latter  cause  is 
rare,  but  a  few  quite  definite  cases  have  been  demon- 
strated. 

Whatever  be  the  cause  of  the  condition,  it  is  char- 
acterized by  hypersemia  and  swelling  of  the  mucous 
membrane;  the  inflammation  is,  as  a  rule,  patchy  at 
first,  and  gradually  spreads  over  larger  areas,  until  in 
some  cases  the  whole  of  the  mucous  membrane  of  the 
mouth  is  involved.  It  is  accompanied  by  the  smarting, 
gritty  feelmg  so  characteristic  of  all  catarrhal  inflam- 
mations. 

Treatment. — First  treat  the  cause  of  the  condition, 
whether  it  be  a  badly-fitting  crown,  a  chronic  gastritis, 
or  an  over-indulgence  in  whisky  without  the  soda. 

For  many  years  it  has  been  the  custom  to  prescribe 
potassium  chlorate  as  a  specific  for  stomatitis.  Re- 
cently, however,  some  doubts  have  been  cast  upon  its 
efiicacy.  Potassium  chlorate  may  be  given  either  as 
a  mouth-wash,  gr.  xxv  ad.  ^i  of  water,  to  be  diluted 
before  use  with,  an  equal  quantity  of  hot  water,  or  in 
the    form     of    lozenges     (gr.    iii    B.P.).     Formamint 


1 68  SURGERY  FOR    DENTAL    STUDENTS 

lozenges  are  also  advised  in  this  condition,  and  as  in 
the  great  majority  of  cases  infection  by  micro- 
organisms is  an  important  etiological  factor,  the 
bactericidal  action  of  the  formalin  contained  in  the 
formamint  is  of  value.  Care  should  be  exercised  in 
prescribing  formamint  in  those  cases  where  a  chronic 
condition  in  the  gastro-intestinal  tract  is  present;  for- 
malin is  very  irritating  to  some  gastric  mucous  mem- 
branes, and  the  treatment  must  be  stopped  at  the  first 
sign  of  ill-effects  in  the  stomach. 

in  severer  cases,  a  mouth-wash  of  liq.  sodas 
chlorinatas  5i  ad.  ji,  or  hydrogen  peroxide,  may  be 
given. 

Ulcerative  Stomatitis  usually  occurs  as  a  later  stage 
of  an  untreated  catarrhal  inflammation.  The  clinical 
picture  is  similar,  the  pain  being  more  severe,  and 
the  mucous  membrane  being  ulcerated.  It  should  be 
treated  on  similar  lines  to  the  catarrhal  variety. 

In  cases  due  to  infection  by  the  pneumococcus,  there 
is  usually  considerable  ulceration,  and  destruction  of 
gum.  The  treatment  of  these  cases  is  very  tedious. 
Bacteriological  treatment  has  met  with  little  or  no 
success.  In  a  case  which  came  under  the  author's 
notice,  the  patient  (a  child  of  about  lo,  in  whom  the 
gum  around  the  six  lower  incisors  w^as  chiefly  affected) 
was  treated  first  with  silver  nitrate  solution,  and  later 
the  gums  were  regularly  painted  with  tincture  of 
iodine.  Progress  was  slow,  but  ultimately  cure  re- 
sulted. This  patient  had  previously  been  treated  with 
vaccines   without   success. 

Aphthous  Stomatitis  is  a  condition  characterized 
by  the  presence  of  exquisitely  painful,  minute,  white 
spots  on  the  buccal  mucous  membrane.  They  should 
be  treated  by  cauterization  with  copper  sulphate  or 
solid  silver  nitrate.  Attention  should  also  be  paid  to 
the  gastro-intestinal  tract,  upon  some  chronic  condition 
of  which  aphthous  stomatitis  frequently  depends. 

Mercurial  Stomatitis  is  described  in  a  separate  para- 
grapli  because  it  is  such  a  common  condition.  But  it 
actually  consists  of  a  severe  catarrhal  stomatitis, 
rapidly  progressing  to  ulceration.  As  its  name  im- 
plies, the  condition  results  from  the  prolonged  use  of 
mercury.  By  far  the  most  common  malady  in  which 
the   prolonged   use   of  mercury  is   advised  is   syphilis, 


DISEASES    OF    THE   MOUTH  169 

and,  consequently,  severe  stomatitis  is  often  found  in 
patients  sutfering  from  syphilis.  A  special  form  of 
stomatitis,  known  as  syphilitic  stomatitis,  is  described, 
but  it  seems  highly  probable  that  this  condition  is  due, 
not  to  the  sypliilis,  but  to  the  mercury  prescribed  to 
cure  it;  and  that  it  should  therefore  be  classed  as  mer- 
curial stomatitis.  As  'mentioned  above,  the  disease 
begins  as  a  simple  catarrhal  inflammation,  the  mucous 
membrane  being  red  and  inflamed,  and  ,the  salivary 
secretion  being  markedly  increased.  There  is  usually 
considerable  pain,  and  a  metallic  taste  in  the  mouth. 
The  condition  progresses  rapidly,  the  gums  becoming 
very  painful,  soft,  ulcerated  and  readily  bleeding.  The 
breath  is  offensive  and  the  teeth  tend  to  become  loose. 

The  treatment  consists  in  withholding  the  mercury, 
and  employing  the  methods  of  local  treatment  advised 
for  the  ulcerative  variety. 

Gangrenous  Stomatitis  is  a  severe  condition  resulting 
from :  — 

(i)  Septic  infection  of  ulcerative  stomatitis. 

(2)  As  a  complication  of  acute  specific  fevers, 
especially  in  measles,  in  debilitated  children  in  that 
section  of  the  community  in  which  oral  hygiene  is  not 
practised. 

(3)  In  old  people  suffering  from  chronic  debilitating 
diseases,  such  ,as  diabetes  or  chronic  Bright's  disease, 
combined  with  oral  sepsis. 

(4)  In  neglected  mercurial  stomatitis. 

As  its  name  suggests,  the  condition  results  in  con- 
siderable destruction  of  the  tissues  of  the  gums,  lips 
and  cheeks.     Necrosis  of  the  jaws  may  also  occur. 

In  children,  this  condition  is  known  as  Cancrum 
oris  (see  Chapter  V),  and  is  an  extremely  fatal  malady, 
occurring  as  it  does  in  patients  whose  resisting  power 
is  already  undermined  by  poverty,  starvation  and  dirt. 
A  similar  condition  attacks  the  vulva,  and  is  known  as 
Noma  viilvce. 

Treatment  (see  Cancrum  oris.  Chapter  V). 

Thrush  is  a  condition  occurring  chiefly  in  underfed 
and  dirty  children,  and  is  due  to  the  presence  of  a 
parasitic  fungus,  Oidium  albicans.  White  patches 
appear  on  the  buccal  mucous  membrane,  most  com- 
nionlv  inside  the  cheeks.  The  patches  resemble  spots 
of  milk.     They  are  difficult  to  describe  accurately,  but. 


\/' 


170  SURGERY   FOR    DENTAL    STUDENTS 

when  once  seen,  are  very  easy  to  recognize.  The 
student  should  embrace  every  opportunity  of  inspecting" 
the  patches  for  himself. 

Treatment. — The  general  condition  must  first  be 
treated;  the  mouth  must  be  kept  clean  as  far  as  pos- 
sible, special  cleanliness  being  insisted  upon  in  regard 
to  drinking  and  feeding  vessels.  The  patches  them- 
selves should  be  painted  with  glycerine  of  borax. 

Salivary  Calculus  is  described  in  detail  in  text-books 
on  dental  surg'ery. 

Cysts  of  the  Floor  of  the  Mouth— 

A  Ranula  is  a  cystic  swelling  in  the  floor  of  the 
mouth  connected  with  one  of  the  glands  in  the  neigh- 
bourhood, or  their  ducts.  A  ranula  usually  appears 
as  a  unilateral  cystic  swelling,  often  as  large  as  a 
walnut,  and  sometimes  larger,  containing  thick,  mucous 
fluid.  When  quite  small,  e.g.,  the  size  of  a  pea,  these 
cysts  are  often  termed  mucous  cysts. 

Treatment  consists  in  dissecting  out  as  much  of  the 
cyst  wall  as  possible.  Any  of  the  cvst  wall  which  can- 
not be  removed  should  be  cauterized  with  pure  carbolic 
acid. 

Dermoid  Cysts  also  occur  in  the  floor  of  the  mouth. 
They  differ  from  ranulse  in  'being  more  common  in 
the  middle  line,  while  ranulae  are  almost  invariably  on 
one  side;  and  also  in  containing  cheesy,  sebaceous 
material. 

Treatment  is  similar  to  that  advised  for  ranulse. 

Syphilis. — Primary  Chancres  (vide  Chapter  XII) 
occur  on  the  lip,  which  is  perhaps  the  commonest 
position  for  an  extragenital  chancre.  The  usual 
characters  of  a  hard  chancre  are  present,  and  the 
submaxillary  lymphatic  glands  are  enlarged.  The 
diagnosis  of  this  condition  from  those  with  which  it 
is  most  likely  to  be  confused,  namely  epithelioma, 
gumma  and  tubercle,  is  treated  in  a  little  detail  in  the 
chapter  on  Diseases  of  the  Tongue  (Chapter  XXII). 

Mucous  patches  frequently  occur  in  the  mouth,  and 
are   extremely  contagious   (znde  Chapter  XII). 

Gunimata  also  occur. 

The  treatment  of  syphilis,  when  it  affects  the  mouth, 
differs  in  no  way  from  the  treatment  of  the  disease 
in  other  situations. 


DISEASES    OF    THE    MOUTH  I7I 

Tuberculous  Ulceration  is  not  common. 

Carcinoma  occurs  most  commonly  as  an  epithelioma. 
It  is  more  frequent  in  the  lower  than  the  upper  lip. 
The  signs  and  treatment  of  this  condition  are  described 
in  dealing  with  epithelioma  of  the  tongue  (Chapter 
XXII). 

Herpes  labialis  is  a  vesicular  eruption  which  affects 
a  small  area  on  the  lip.  It  is  often  somewhat  painful. 
It  occurs  during  the  course  of  such  maladies  as  a 
common  cold,  influenza,  pneumonia,  cerebro-spinal 
meningitis,  and  other  conditions.  It  must  not  be  con- 
fused with  Herpes  Zoster,  which  is  described  in  Chap- 
ter IX.  Local  treatment  is  rarely  required.  The  patch 
may  be  dusted  with  boracic  powder  if  necessary. 

Congenital  Conditions — 

Macrocheilia  {vide  Chapter  X). 

Hare-lip  and  Cleft-palate. — These  two  conditions 
are  so  intimately  associated  with  one  another  that  it 
will  simplify  matters  to  consider  them  together. 

Hare-lip  is  a  congenital  condition  in  which  imperfect 
development  results  in  a  cleft  in  the  lip.  The  con- 
dition varies  considerably  in  degree ;  it  may  involve 
the  lip  only;  the  cleft  may  run  further  upwards  into 
the  nostril,  or  the  alveolus  of  the  superior  maxilla  may 
be  included  in  the  deformity.  It  may  be  rmilateral  or 
bilateral,  and  may  or  may  not  be  associated  with  cleft- 
palate. 

Cleft-palate  is  a  similar  condition  affecting  the  palate, 
resulting  again  from  imperfect  development.  As  in 
hare-lip,  the  extent  of  the  cleft  varies  considerably, 
from  a  mere  bifid  uvula  or  a  cleft  soft  palate  to  a  cleft 
involving  hard  palate  as  well.  In  addition,  hare-lip 
may  or  may  not  be  present. 

It  will  be  necessary  to  the  proper  understanding  of 
what  follows  that  we  should  allude  briefly  to  the 
developmental  features. 

The  fronto-nasal  process,  passing  downwards  from 
above,  divides  into  two  processes  each  side,  an  in- 
ternal and  an  external  nasal  process.  From  the  sides 
of  the  head  advance  the  two  maxillary  processes.  These 
processes  should  all  unite  to  form  the  upper  part  of 
the  normal  face.  If  for  some  reason  they  fail  to  unite, 
an  abnormal  cleft,  either  in  lip  or  palate,  or  in  both 
results. 


172  SURGERY   FOR    DENTAL    STUDENTS 

Many  battles  have  been  foiight  over  the  qiiestion  of 
the  anatomical  relations  of  the  cleft.  Until  last  year 
it  was  generally  held  that  the  cleft  passed  between  the 
central  and  lateral  teeth.  But  Professor  Keith  has 
recently  shown  several  specimens  in  which  the  cleft 
passes  actually  through  the  socket  of  a  tooth.  Pro- 
fessor Keith's  paper  is  of  immense  interest  and 
scientific  value,  and  will  well  repay  careful  study. 

Treatment. — The  treatment  of  these  conditions  is 
always  operative,  except  perhaps  in  the  case  of  a  simple 
bifid  uvula,  which  may  not  demand  any  treatment. 
The  main  question  to  be  considered  is  when  the  opera- 
tion is  to  be  performed.  It  should  be  done  as  soon  as 
the  child's  physical  condition  is  such  as  to  enable  it  to 
pass  through  the  ordeal  satisfactorily.  In  a  healthy 
child  the  operation  can  usually  be  safely  undertaken  at 
from  six  wrecks  to  three  months  after  birth,  according 
to  the  size  of  the  child.  Operation  should  be  delayed 
if  the  child  is  weakly;  and  if  any  septic  condition  of 
the  nose  or  mouth,  such  as  snuffles,  stomatitis,  &c.,  is 
present,  this  should  be  dealt  with  before  operation  is 
attempted.  Operative  measures  should  always  be 
completed  when  practicable  before  the  commencement 
of  teething. 

Operation  will  require  to  be  performed  earlier  than 
usual,  if  the  child  is  suffering  from  an  inability  to  suck 
due  to  the  developmental  defect.  The  details  of  the 
various  operations,  which  are  performed  in  the  different 
degrees  of  the  condition,  appear  most  unpleasantly 
complicated  in  text-book  descriptions,  but  become 
comparatively  simple  when  the  actual  operation  is  seen. 
The  student  should,  therefore,  make  a  point  of  being 
present  at  the  performance  of  these  operations,  when 
he  will  find  them  quite  easy  to  understand,  and  by  care- 
fully watching  the  operator  he  will  find  his  difficulty 
in  grasping  the  details  rapidly  disappear. 

The  essential  points  in  the  operation  for  hare-lip  are 
as  follows  :  — 

The  buccal  mucous  membrane  is  cut  through  at  the 
point  where  it  is  reflected  from  the  lip  to  the  labial 
surface  of  the  superior  maxilla,  and  the  lip  is  freely 
dissected  away  from  the  maxilla.  In  a  single  hare-lip 
two  crescentic  incisions  are  now  made,  one  on  each 
side     of     the     cleft,     these     incisions     joining     above 


DISEASES    OF    THE    MOUTH 


U3 


(fig.  15).  The  edges  of  the  cleft  are  now  pared  along 
the  lines  of  these  incisions,  the  raw  surfaces  thus 
formed  being  subsequently  drawn  together  and 
stitched  by  means  of  deep  silver-wire  stitches  (two  in 
number  as  a  rule),  and  a  varying  number  of  horsehair 
or  catgut  stitches.  The  appearance  at  the  end  of  the 
operation  is  shown  in  fig.  16).    A  collodion  dressing  is 


Fig.   15. — Hare-lip,  shewing  incisions. 


Fig.  16. — Hare-lip  ;  operation  completed. 


then  applied.  Tile  silver-wire  stitches  are  usually 
removed  on  the  fourth  day,  and  the  horsehair  stitches 
at  the  end  of  a  week  or  ten  days. 

The  details  of  the  operation  are  subject  to  variations 
dependent  upon  the  extent  of  the  cleft,  but  the  main 
essentials  are  the  same. 

The  operation  required  for  the  restoration  of  a  cleft- 
palate  is  briefly  as  follows  :  — 

Two  curved  incisions  are  made  in  the  mucous  mem- 


1/4 


SURGERY  FOR  DENTAL  STUDENTS 


brane  of  the  palate,  one  on  either  side  of  the  cleft. 
These  incisions  should  run  parallel  to  the  upper  teeth, 
and  about  half  an  inch  internal  to  their  lingual  surface. 
The  length  of  the  incisions  will,  of  course,  depend  upon 
the  extent  of  the  cleft.  The  soft  tissues  internal  to 
these  incisions  are  then  stripped  off  the  bone,  so  that 
two  flaps  are  obtained,  consisting  of  all  the  soft  tissues 
of  the  palate,  these  flaps  remaining  fixed  at  each  end. 

The  edges  of  the  cleft  are  then  pared  (in  the  same 
way  as  in  the  operation  for  hare-lip),  brought  together 
in  the  middle  line,  and  secured  by  silver-wire  stitches. 


Fig.  17.  — Cleft-palate  ; 
shewing  incisions. 


Fig.  18.— Cleft-palate  ; 
operation  completed. 


In  order  to  avoid  excessive  tension  on  the  stitches, 
the  original  incisions  are  prolonged  backwards  a  short 
distance. 

Acquired  Perforations  of  the  palate  are  almost  m- 
variably  due  to  injury  or  tertiary  syphilis,  the  latter 
being  by  far  the  most  frequent  cause.  Tuberculous 
disease  is  rare. 

Ulceration  of  the  palate  may  occur  as  part  of  an 
ulcerative  stomatitis.  Most  commonly  it  is  syphilitic 
or  malignant;  more  rarely  it  may  be  tuberculous. 

Tumours  of  the  palate. — Simple  tumours  are  rare, 
the  most  common  being  fibromata. 


DISEASES    OF    THE    MOUTH  175 

Malignant  tumours,  both  epitheliomatous  and  sar- 
comatous, occur,  usually  by  extension  from  neighbour- 
ing- tissues,  such  as  the  jaw  or  tonsils. 

Tonsils- 
Acute  catarrhal  tonsillitis  occurs  in  association  with 
pharyngitis  as  the  ordinary  "  sore  throat."  It  should 
be. treated  by  the  administration  of  potassium  chlorate 
gargle.  Ihe  possibility  of  a  sore  throat  being-  the 
first  sign  ot  the  onset  of  an  acute  specific  fever,  such 
as  scarlet  fever  or  diphtheria,  should  never  be  lost 
sight  of,  especially  in  children. 

Acute  follicular  tonsillitis  is  an  infective  inflammation 
resulting  m  enlargement  of  the  tonsils,  accompanied 
by  pain  and  redness  of  the  tonsillar  mucous  membrane. 
A  membranous  deposit  occurs  in  patches  on  the 
tonsils.  The  membrane  is  confined  to  the  tonsils,  and 
the  underlying  tissues  do  not  bleed  when  a  piece  of 
membrane  is  carefully  pulled  off.  These  are  two- 
important  points  of  difference  in  the  diagnosis  between 
this  condition  and  diphtheria  {q.v.).  The  temperature 
is  usually  high  {e.g.,  103°  or  104^  F.),  v^hich  is  higher 
than  is  usual  in  diphtheria.  The  cervical  glands  are 
often  enlarged.  The  condition  may  usually  be  distin- 
guished from,  scarlet  fever  by  the  absence  of  the  typical 
*'  strawberry  tongue  "  and  characteristic  rash,  and. 
also  the  fact  that  the  membrane  is  confined  to  the 
tonsils. 

Treatment. — The  patient  should  be  confined  to  bed, 
and  a  smart  purge  administered.  A  glycerine  of  bella- 
donna fomentation  should  be  applied  to  the  neck  to 
relieve  the  pain,  and  a  gargle  of  hydrogen  peroxide  or 
liq.  sodse  chlor.  given.  Minim  doses  of  tinct.  aconiti 
may  be  useful  if  the  fever  is  pronounced. 

Quinsy. — This  condition  is  often  spoken  of  as  acute 
suppurative  tonsillitis,  but  it  actually  is  a  combination 
of  acute  tonsillitis  and  suppuration  around  the  tonsil, 
i.e.,  peritonsillar  abscess.  It  should  be  treated  in  the 
same  way  as  follicular  tonsillitis  in  the  early  stages, 
but  when  a  definite  peritonsillar  abscess  is  present 
this  should  be  incised  under  cocaine  and  the  pus 
evacuated. 

Diphtheria  is  an   acute   specific   disease   due   to  the 
presence   of  the  Bacillus  diphtheria,    or  Klebs-Loffler 


176  SURGERY   FOR    DENTAL    STUDENTS 

"bacillus.  The  organism  is  slender  and  rod-shaped;  it 
is  Gram  positive,  but  takes  the  stain  somewhat  irre- 
gularly. Several  organisms  very  similar  to  the  Klebs- 
Loffler  bacillus  exist,  and  a  special  method  of  staining 
(Neisser's  method"^)  has  to  be  employed  in  order  to 
•distinguish  between  them. 

The  disease  is  characterized  by  a  local  membranous 
deposit,  accompanied  by  general  constitutional  sym- 
ptoms. The  membrane  usually  appears  first  upon  the 
tonsils,  fauces,  and  soft  palate,  whence  it  may  spread 
to  the  nose  or  larynx.  More  rarely  it  is  primary  in 
the  nose  or  larynx.  In  still  rarer  cases,  diphtheritic 
membrane  may  form  upon  the  skin  in  other  parts  of 
the  body,  usually  upon  some  slight  wound. 

The  incubation  period  of  diphtheria  is  usually  from 

two  to  four  days.     The  disease  reveals  itself  by  general 

malaise,   slight  fever,   not  usually  more  than   101°  F. 

{cf.  tonsillitis),   headache,    and   sore  throat.     At  first, 

the  membrane  takes  the  form  of  whitish-yellow  dots 

of  deposit,  which  gradually  coalesce  and  spread  over 

'.larger  areas.     As  the  disease  progresses  the  membrane 

becomes    darker    in    colour,     and    thicker.     However 

-carefully  it  be  pulled  off,  the  underlying  tissues  bleed, 

:and  a  raw  surface  is  left,  upon  which  the  membrane 

reforms.     The    disease   varies    in    severity   from  cases 

"in    which    no    membrane    is    present    (the    diagnosis 

^depending      upon      bacteriological      examination)      to 

-extremely  severe  cases  where  a  black  sloughing  mass 

-'is  seen  in  the  throat  and  grave  constitutional  symptoms 

are  present.     Extreme  dyspnoea  may  occur,   so  grave 

.as     to     necessitate     the     immediate     performance     of 

tracheoto^ny   or  intubation.     The   former  is   described 

below.     Intubation  is   an   operation  which  consists   of 

passing    a    special,     flexible,     metal    tube    down    the 

trachea  past  the  obstruction. 

The  chief  complications  are:  Otitis  media  from 
•direct  extension,  cardiac  failure,  and  acute  nephritis. 
Later  on,  diphtheritic  paralysis  may  ensue,  neither 
less  frequently  nor  less  severely  in  the  mild  than  in 
the  severe  cases.  The  palate  is  most  frequently 
affected,  then  the  muscles  of  the  eyes,  and,  least  often, 
the  limbs  and  other  muscles. 

*  A  combination  of  methylene  blue  and  Bismarck  brown,  by  which  the 
irregular  staining  of  the  organisms  is  shewn. 


DISEASES    OF    THE    MOUTH  I77 

The  diagnosis  is  made  from  the  points  already 
mentioned,  i.e.,  the  appearance  of  the  membrane,  and 
the  shght  pyrexia.  A  bacteriological  examination  of 
a  swab  from  the  throat,  if  positive,  settles  the  matter. 

The  treatinent  of  diphtheria  belongs  more  to  the 
domain  of  medicine  than  surgery,  and  therefore  is  not 
discussed  in  detail  here.  The  employment  of  diphtheria 
antitoxin  has  revolutionized  the  treatment,  and  has 
had  a  wonderful  effect  in  reducing  the  death-rate  from 
the  disease. 

Since  the  introduction  of  the  antitoxin  treatment, 
the  necessity  for  the  performance  of  tracheotomy 
is  of  much  rarer  occurrence.  But  the  operation  is 
necessary  in  certain  cases,  and  .therefore  this  is  an 
appropriate  moment  for  a  brief  description.  Some  of 
the  other  conditions  in  which  the  performance  of 
tracheotomy  may  be  required  are :  The  removal  of 
foreign  bodies  from  the  air  passages;  cases  where 
there  is  pressure  on  the  trachea  (e.g.,  from  malignant 
disease  of  the  thyroid),  or  cases  of  injury  to  the  air 
passages. 

The  operation  may  be  performed  in  three  situa- 
tions :  — 

(i)  Above  the  isthmus  of  the  thyroid :  High 
operation. 

(2)  Through  the  isthmus  of  the  thyroid :  Median 
operation. 

(3)  Below  the  isthmus  of  the  thyroid :  Low  opera- 
tion. 

The  High  operation  is  the  easiest,  and  is,  therefore, 
most  frequently  performed. 

Place  the  patient,  usually  a  child,  on  its  back.  The 
operator  stands  on  the  right  side  of  the  patient,  and 
an  assistant  behind  the  patient's  head.  The  duty  of 
this  assistant  is  to  see  that  throughout  the  perform- 
ance of  the  operation  the  patient's  head  is  kept 
accurately  in  the  middle  line.  If  an  anaesthetic  is  being 
given  the  anaesthetist  sltould  stand  opposite  the 
surgeon.  Other  assistants  will  be  required  to  control 
the  patient's  movements. 

The  first  step  is   to   find  the   cricoid   cartilage,    and 

steady  it  with  the  left  thumb  and  finger.     The"  cricoid 

cartilage  should  be  held  thus  until  the  completion  of 

the     operation.      A     median     incision    is    then    made 

12 


1/8  SURGERY   FOR    DENTAL    STUDENTS 

vertically  downwards  for  about  an  inch  and  a  half 
from  the  centre  of  the  cricoid  cartilage.  The  length 
of  the  incision  will,  of  course,  depend  upon  the  age 
and  size  of  the  patient.  The  underlying  tissues  are 
then  divided  in  the  same  line  until  the  sternohyoid 
and  sternothyroid  muscles  are  exposed.  The  fascia 
connecting  the  muscles  of  the  two  sides  together  is 
divided  with  the  handle  of  the  knife.  The  surgeon 
now  draws  aside  the  muscles  of  each  side  with  re- 
tractors. These  retractors  should  be  controlled  by  the 
assistant  wdio  is  holding  the  head;  the  muscles  m.ust 
be  retracted  equally  on  both  sides,  so  that  the  further 
incisions  may  still  be  made  accurately  in  the  middle 
line;  the  patient's  head  can  still  be  controlled  by  the 
forearms  of  the  assistant.  By  pulling  the  thyroid 
isthmus  downwards  with  a  retractor,  the  trachea  will 
be  exposed,  and  an  incision  should  be  made  into  it, 
in  the  middle  line,  the  knife  being  held  with  the  cutting' 
edge  turned  upwards  towards  the  cricoid  cartilage, 
adopting  the  same  precautions  as  recommended  in  the 
operation  of  laryngotomy  (see  p.  164),  in  order  to 
avoid  injury  to  the  posterior  tracheal  wall,  or  important 
structures  behind  it. 

As  in  laryngotomy,  venous  haemorrhage  is  usually 
profuse,  but  it  will  generally  cease  as  soon  as  the 
tracheal  incision  has  been  made.  If  serious  bleeding" 
occurs,  a  wise  precaution  is  to  apply  four  pairs  of 
Spencer  Wells'  forceps,  one  at  each  end  of  the  incision, 
on  each  side.  One  of  the  authors  has  seen  a  case  in 
which  high  tracheotomy  was  being  performed  upon 
a  baby  with  diphtheria;  though  profuse  hgemorrhage 
occurred,  the  surgeon  proceeded  with  the  operation, 
trusting  that  the  haemorrhage  would  cease  as  soon 
as  he  penetrated  the  trachea.  But,  as  a  matter  of 
fact,  a  large  vein,  probably  one  of  the  innominate 
veins  in  an  abnormal  position  had  been  wounded,  and 
death  occurred  in  about  a  minute.  An  accident  of 
this  type  is  of  quite  rare  occurrence,  but  the  fact  that 
it  may  occur  should  always  be  borne  in  mind.  In 
this  connection,  we  would  impress  upon  the  reader  that 
these  vital  structures  are,  in  the  case  of  young  children, 
crowded  together  in  a  surprisingly  small  space,  and 
that  our  notions  of  their  anatomical  relations,  learnt 
in   the   dissecting-room,    will   not   serve   us   unless   we 


DISEASES    OF    THE    MOUTH  1/9 

bear  in  mind  the  great  difference  in  these  relations  in 
infancy. 

When  the  trachea  has  been  opened,  tracheal  dilators 
are  passed  into  it.  The  metal  tracheotomy  tube  must 
then  be  inserted.  In  diphtheria,  it  is  wise  to  hold  open 
the  trachea  with  the  dilators  until  all  loose  membrane 
has  been  coughed  up,  before  inserting  the  tube.  The 
tube  is  then  secured  by  tapes,  attached  to  it  on  each 
side,  and  tied  round  the  neck. 

The  Lozv  operation  is  much  more  difficult,  on 
account  of  the  greater  depth  of  the  trachea,  the  closer 
proximity  of  the  large  venous  trunks,  and  the  possible 
presence  of  the  occasional  throidea  ima  artery.  If 
the  obstruction  to  respiration  necessitating  operation 
is  low  down,  the  Low  operation  may  be  necessary,  but 
apart  from  considerations  of  that  kind,  it  is  rarely 
chosen.  The  steps  are  similar  to  those  of  the  High 
operation. 

TJie  Median  operation  is  rarely  performed.  In  the 
hands  of  an  expert  it  is,  perhaps,  quicker  than  the 
high  operation.  The  incision  is  made  right  through 
the  isthmus,  dividing  it  completely.  The  haemorrhage 
from  the  isthmus  can  be  disregarded  until  the  dilators 
have  been  inserted  into  the  trachea. 

Chronic  Enlargement  of  the  Tonsils  is  a  common 
condition  in  children,  especially  weakly,  strumous 
children;  it  is  very  commonly  associated  with  the 
presence  of  adenoids  {q-V.)- 

Treatment  consists  in  removal  of  the  enlarged 
tonsils,  combined  with  general  hygienic  measures  and 
the  administration  of  tonics,  such  as  cod-liver  oil,  &c. 

There  are  two  methods  of  removing  enlarged 
tonsils  :  — 

(i)  With  an  instrument  known  as  a  Gttillotine,  by 
means  of  which  the  superficial  two-thirds,  more  or  less, 
can  be  removed. 

(2)  By  enucleation,  that  is  to  say,  dissecting  out  the 
whole  tonsil. 

Syphilis  may  affect  the  tonsil,  either  in  the  form  of 
secondary  ulceration,  or  gummata. 

Sarcoma  and  Carcinoma  may  both  affect  the  tonsil. 
The  operation  for  the  removal  of  a  malignant  growth 
in  this  region  is  extremely  difficult  and  extensive,  and 
the  disease  is  very  liable  to  recur. 


l80  surgery  for  dental  students 

Diseases  of  the  Pharynx. 

Adenoids  are  small,  lymphoid  growths  at  the  back 
of  the  nose,  which  are  commonly  associated  with 
chronic  tonsillar  enlargement.  Their  presence^  has 
considerable  effect  upon  the  development  of  the  jaws, 
for  a  descriplion  of  which  a  text-book  on  dental 
surgery  should  be  consulted.  The  !treatment  is  to 
remove  the  growths. 

Acute  Pharyngitis  is  generally  associated  with  acute 
catarrhal  tonsillitis  (q.'V.)  and  requires  similar  treat- 
ment. 

Chronic  Pharyngitis  occurs  as  the  result  of  over- 
use or  misuse  of  the  voice  (the  so-called  clergyman's 
sore  throat),  or  some  chronic  irritation,  such  as  con- 
stant cigarette  smoking  or  spirit  drinking". 

The  symptoms  of  the  disease  are  hoarseness,  tired- 
ness, and  loss  of  voice,  and  a  dry  cough.  On  examina- 
tion, the  follicles  will  be  seen  to  be  enlarged. 
Excessive  cigarette  smoking  results  in  a  dullish  red 
appearance  of  the  pharyngeal  mucous  membrane, 
mottled  with  white  spots,  which  is  very  characteristic. 

Treatment. — First  remove  the  cause  of  the  disease. 
The  pharynx  may  then  be  painted  with  glycerine  of 
tannic  acid,  or  an  ammonium  chloride  inhaler  may  be 
used.*  When  the  follicles  are  much  enlarged,  they 
may  be  touched  with  the  electrocautery  under  cocaine 
ansesthesia. 

Syphilis  commonly  affects  the  pharynx.  In  the 
secondary  stage,  pharyngitis,  mucous  tubercles,  and 
ulceration  occur. 

In  the  tertiary  stages,  gummata  may  involve  the 
pharynx. 

Carcinoma  and  Sarcoma  may  occur  in  the  pharynx. 
As  was  mentioned  in  dealing  with  malignant  disease 
of  the  tonsil,  the  operative  treatment  of  these  growths 
is  very  extensive  and  difficult. 

Retropharyngeal  Abscess  may  be  acute  or  chronic. 
The  acute  cases  usually  result  from  infection  following 
pharyngitis  in  children.  The  condition  is  a  grave  one, 
as  the  pus  may  burrow  in  various  directions,   and   is 

*  A  complicated  apparatus,  in  which  by  the  interaction  of  hydrochloric 
acid  and  ammonia,  ammonium  chloride  vapour  is  given  off,  and  inhaled 
through  a  tube. 


DISEASES    OF    THE    MOUTH  l8l 

difficult  to  evacuate  completely.  Considerable  con- 
stitutional disturbance  generally  accompanies  the  con- 
dition, while  dysphagia  and  dyspnoea  may  result  from 
the  local  swelling. 

Treatment  consists  in  immediate  operation  to 
evacuate  the  pus. 

Clironic  cases  are  almost  always  the  result  of  tuber- 
culous disease  of  the  cervical  spine  (q.v.). 


CHAPTER  XXII. 
DISEASES    OF   THE   TONGUE. 

Tongue-tie  is  a  congenital  condition  in  which  the 
frenum  is  abnormally  short,  and  its  attachment  may 
extend  forward  so  as  to  approach  very  closely  the 
necks  of  the  lower  incisors.  In  most  cases,  the  frenum 
lengthens  as  the  child  grows,  and  no  treatment  is 
required.  If  the  defect  interferes  wath  the  child's 
ability  to  suck,  the  frenum  must  be  snipped  through. 
I  It  should  be  cut  transversely,  close  to  the  symphysis. 
^-^^  The  tongue  should  then  be  pulled  forward,  so  that 
the  transverse  slit  is  stretched  into  a  longitudinal  one, 
and  the  sides  of  the  wound  drawn  together  and 
stitched.  This  procedure  is  adopted  in  order  to  avoid 
the  scarring  which  takes  place  if  the  frenum  be  just 
carelessly  snipped  through  and  left;  in  cases  so 
treated  the  condition  after  operation  becomes  fre- 
quently worse  than  it  was  before. 

Wounds  of  the  Tongue.— The  commonest  accident 
to  the  tongue  is  a  bite,  either  from  a  fall  with  the 
tongue  between  the  teeth,  or  during  an  epileptic  fit. 
In  epilepsy,  during  the  fit,  a  pencil  or  a  cork  should 
be  placed  between  the  teeth  to  prevent  this  accident. 

Hemorrhage  from  a  bitten  tongue  is  rarely  severe. 
It  can  usually  be  controlled  by  giving-  the  patient  ice 
to  suck.  If  an  artery  can  be  seen  spirting,  it  should 
be  seized  with  artery  forceps  and  ligatured.  If  neces- 
sary, one  or  more  stitches  may  be  inserted  '\n  the 
wound.  In  very  severe  cases,  it  may  be  necessary 
to  ligature  the  lingual  artery  through  an  incision  in 
the  neck. 

To  expose  the  lingual  artery  in  the  submaxillary 
triangle  of  the  neck,  two  points  are  taken,  one  an 
inch  below  and  external  to  the  point  of  the  chin,  and 
the  other  just  above  and  behind  the  angle  of  the  lower 
jaw.  A  crescentic  incision  is  then  made  joining  these 
two  points  (fig.   19). 


DISEASES    OF   THE    TONGUE 


i^3 


The  atter-treatment  of  a  wound  of  the  tong'ue  con- 
sists chiefly  in  cleanhness.  Liquid  food  should  be 
i^'iven,  and  the  mouth  should  be  carefully  and  fre- 
quently washed  out  with  weak  boracic  or  peroxide 
lotion,  especially  after  meals. 

Burns,  Scalds,  and  Stings  of  insects  may  be  danger- 
ous, on  account  of  the  swelling  of  the  tongue,  and 
consequent  dyspnoea  which  may  result.  Ice  should 
be  given  to  suck;  if  there  is  much  swelling_^  super- 
ficial incisions  may  be  made  in  the  tongue.  In  very 
urgent  cases,  laryngotomy  may  be  required.  For 
insect  stings,  solid  bicarbonate  of  soda  is  a  good  local 
application,  on  account  of  its  action  in  neutralizing 
the  acid  injected  by  the  insect. 


Fig.    19. — Incision   for  ligature   of   the  lingual  artery  in  the  neck 
(The  dotted  line  indicates  the  lower  margin  of  the  mandible.) 


Acute  Inflammation  of  the  Tongue  (acute  paren- 
chymatous glossitis)  is  an  uncommon  condition.  It 
may  occur  as  the  result  of  mercurial  treatment,  or 
follow  a  septic  wound  or  an  insect  sting.  The  tongue 
is  swollen,  painful,  and  inflamed,  and  the  salivary 
glands  may  be  enlarged. 

Treatment. — In  mercurial  cases,  the  administration 
of  the  drug  should  be  discontinued  at  once.  The 
mouth  should  be  frequently  washed  out  with  boracic 
or  peroxide  lotion.     Potassium  chlorate  lozenges  may 


1 84  SURGERY    FOR   DENTAL    STUDENTS 

be  given,  and  the  bowels  should  be  kept  regular  by 
means  of  saline  purgatives.  If  an  abscess  forms,  it 
should  be  opened  at  once. 

Acute  Superficial  Glossitis  occurs  as  part  of  a 
general  acute  stomatitis  (q.v-)- 

Chronic  Superficial  Glossitis  is  a  condition  of  con- 
siderable importance  on  account  of  the  frequency  with 
which,  if  untreated,  it  develops  into  epithelioma.  It 
is  of  the  greatest  importance  that  the  dental  specialist 
should  be  fully  aware  of  the  gravity  of  the  condition 
and  be  prepared  to  recognize  its  presence,  as  a  timely 
diagnosis  on  his  part  may  constrain  the  patient  to 
seek  surgical  advice  at  a  period  in  the  disease  when 
appropriate  treatment  will  effect  a  cure. 

The  condition  occurs  more  frequently  in  men  than 
women,  usually  after  40  years  of  age.  It  may  be  the 
result  of  any  chronic  irritation,  of  which  excessive 
smoking,  especially  when  a  broken  clay  pipe  is  used; 
roughened  teeth;  ill-fitting  crowns  and  dentures;  and 
spirit  drinking,  especially  when  neat  spirits  are  taken 
constantly,  are  common  examples.  It  may  also  be 
due  to   syphilis. 

Several  stages  of  the  malady  are  described,  each 
stage  running  imperceptibly  into  the  succeeding  one. 
At  first,  hypersemic  patches,  due  to  enlarged  papillae, 
occur.  These  patches  are  best  seen  after  pressing 
blotting  paper  on  the  tongue  to  dry  off  the  moisture. 
Later  on,  raised  white  patches  make  their  appear- 
ance. These  patches  consist  of  opaque  and  horny 
epithelium,  heaped  up  on  the  surface.  This  stage  is 
known  as  Leukoplakia.  Still  later,  the  epithelium  is 
shed,  leaving  a  smooth,  red  surface,  upon  which  the 
papillae  are  atrophied.  Cracks,  fissures,  and  even 
ulceration  frequently  occur. 

The  condition  is  generally  accompanied  by  consider- 
able pain  and  tenderness,  with  consequent  difficulty 
in  speech.  Hot  or  irritating  substances,  such  as 
mustard  or  strong  spirits,  cause  pain. 

Treatment. — All  possible  sources  of  irritation  must 
be  removed.  The  teeth  must  be  scaled,  all  carious 
cavities  treated  and  sharp  points  smoothed  down,  and 
any  unsatisfactory  mechanical  apparatus  readjusted. 
Smoking  should  be  forbidden,  as  also  should  spirits  and 
irritating  food.     The  mouth  should  be  kept  clean  by 


DISEASES    OF   THE    TONGUE  185 

means  of  mouth-washes,  which  must  not  be  irritating 
in  character.  Sodium  bicarbonate  gr.  xx  ad.  ji  is  a 
useful  mouth-wash.  Formahn  is  too  irritating  and 
should  not  be  prescribed  for  this  condition.  Caustics 
should  not  be  used,  on  account  of  the  danger  of 
epithelioma.  If  syphilis  is  the  suspected  cause,  anti- 
syphilitic  remedies  should  be  prescribed,  but  careful 
watch  must  be  kept  for  any  signs  of  mercurial 
stomatitis,  the  occurrence  which  is  specially  likely  under 
these  circumstances.  The  patient  must  be  seen  at 
frequent  intervals  in  order  to  watch  for  and  detect 
the  earliest  signs  of  epithelioma. 

Ulceration  of  the  Tongue. 

A  simple  traumatic  ulcer  may  result  from  any  of 
the  local  irritations  mentioned  above.  These  ulcers 
are  very  painful.  The  first  essential  in  the  treatment 
is  to  remove  the  cause.  The  mouth  should  be  kept 
clean  by  means  of  mouth-washes.  The  base  of  the 
ulcer  may  be  cauterized  with  2  per  cent,  chromic  acid, 
under  cocame  anesthesia.  Orthoform  dusted  over  the 
ulcer  will  often  relieve  the  pain  considerably. 

Simple  ulcers  of  the  tongue  are  sometimes  associated 
with  dyspepsia  and  other  chronic  gastro-intestinal 
disorders.  In  these  cases,  the  underlying"  cause  must, 
of  course,  be  dealt  with. 

Ulceration  of  the  tongue  also  occurs  as  part  of  a 
mercurial  stomatitis  {q.v.). 

Syphilis — 

Primary  Chancres  of  the  tongue  are  not  common. 
When  they  occur,  they  have  the  usual  characteristics 
of  a  hard  chancre;  the  tip  of  the  tongue  is  the  most 
usual  position.     (For  differential  diagnosis,  see  p.  187.) 

Mucous  patches  are  common  in  the  secondary  stage. 
In  the  tertiary  stage,  chronic  superficial  glossitis  may 
occur  {q.v.),  or  gummata  may  be  formed. 

Gummata  of  the  tongue  may  be  single  or  multiple. 
They  are  usually  situated  near  the  middle  line,  towards 
the  posterior  part  of  the  organ.  In  the  early  stag'es, 
a  gumma  forms  a  firm  swelling  which  may  be  super- 
ficial or  deep.  Later,  it  softens,  breaks  down,  and 
ulcerates.     The  typical  gummatous  ulcer  of  the  tongue 


1 86  SURGERY    FOR   DENTAL    STUDENTS 

is  oval  and  deep,  with  a  sloughy  base;  the  edges  are 
not  indurated  nor  raised,  but  usually  undermined. 
There  is  no  induration  of  the  base  of  the  ulcer,  nor 
is  there  any  interference  with  the  movements  of  the 
organ.  The  glands  are  not  often  affected.  Gum- 
matous ulcers  are  comparatively  painless.  They 
should  be  treated  with  antisyphilitic  remedies. 

Tuberculous  ulceration  of  the  tongue  is  a  rare  con- 
dition, and  almost  invariably  associated  with  advanced 
tuberculous  disease  of  the  lungs  or  larynx.  When 
these  ulcers  do  involve  the  tongue,  they  present  a  very 
typical  clinical  picture.  The  presence  on  the  tip  or 
side  of  the  tongue  of  a  slow-growing  but  extremely 
painful  ulcer  with  a  pale  surface  and  irregular  edge, 
in  a  patient  suffering  from  phthisis  or  tuberculous 
laryngitis,  is  in  all  human  probability  a  tuberculous 
ulcer. 

Treatfnent. — The  surface  of  the  ulcer  should  be 
scraped  with  a  sharp  spoon,  under  local  or  general 
anaesthesia,  and  cauterized  with  pure  carbolic  acid. 
If  the  local  lesion  is  small  and  the  disease  in  the  lungs 
is  not  advanced,  it  may  be  possible  to  effect  a  cure 
by  excising  the  ulcer. 

Epithelioma  is  by  no  means  a  rare  condition.  It 
affects  men  more  often  than  women,  and  follows 
conditions  similar  to  those  mentioned  as  causes  of 
chronic  superficial  glossitis.  Indeed,  this  latter  con- 
dition is  a  frequent  prelude  to  the  development  of 
malignant  disease.  The  malady  may  start  in  any 
position,  but  is  perhaps  more  common  in  the  anterior 
than  the  posterior  half  of  the  organ.  When  the  con- 
dition is  preceded  by  chronic  superficial  glossitis,  the 
epithelioma  usually  begins  as  a  hard,  warty  growth 
situated  in  one  of  the  fissures  or  cracks  which 
characterize  the  chronic  inflammation.  As  a  rule, 
ulceration  occurs  early;  the  ty])ical  ulcer  presenting 
an  indurated  base,  with  everted,  indurated  edges.  The 
base  of  the  ulcer  is  sloughy,  and  there  is  often  much 
offensive  discharge;  the  breath  also  may  be  particu- 
larly offensive.  The  growth  soon  infiltrates  the 
neighboiu'ing  tissues,  and  an  early  diagnostic  sign  is 
the  interference  with  the  movements  of  the  tongue 
resulting  from  its  fixation  to  surrounding  parts. 
These   ulcers   often   cause  little    or   no    pain.     Neigh- 


DISEASES    OF   THE    TONGUE 


187 


bouring  glands  are  soon  involved.  (For  differential 
diagnosis,  sec  p.   187.) 

Treatment. — Complete  extirpation  of  the  growth, 
with  all  the  neighbouring  glands,  gives  the  only  chance 
of  cure. 

Sarcoma  is  rare. 

Actinomycosis  may  affect  the  tongue  {see  Chapter 
XII). 

The  differential  diagnosis  of  the  various  ulcers  of 
the  tongue  is  of  great  importance.  In  typical  cases 
it  presents  no  great  difficulty,  but  in  the  early  stages 
microscopic  examination  of  a  portion  of  the  tissue 
involved  may  be  necessary  before  a  diagnosis  can  be 
made.     The  following  table  may  be  useful:  — 


Simple  ulcer 

Hard  chancre 

Gumma 

Tubercle 

Epithelioma 

Very  painful  ... 

Not  painful  ... 

Rarely 

Very  pain- 

May    or     may 

painful 

ful 

not  be  painful 

Heals      rapidly 

Heals    rapidly 

Improves 

Very  slow 

Does  not  heal 

under     treat- 

under     mer- 

with po- 

in    heal- 

ment 

cury 

tass  ium 
iodide 

ing,  even 
under 
treatment 

Characters     0  f 

Indolent     sur- 

S 1 0  u  ghy 

Irregu  1  a  r 

Very    hard. 

simple     ulcer 

faces,  indura- 

base, un- 

shape. 

Much   indura- 

{q. v..   Chap- 

tion   around. 

dermined 

Pale  sur- 

tion.      Edges 

ter  IV). 

Not  fixed 

edges. 

face.    No 

everted.       Of- 

Notfixtd 

indura- 
tion. Not 
fixed 

fensive        dis- 
charge.   Fixed 
to  surrounding 
tissues 

Glands  not  af- 

Glands   en- 

Glands 

G  lands 

Glands     en- 

fected 

larged      and 

not     af- 

rarely 

larged     early, 

tender 

fected 

enlarged 

and  ver)^  hard 

May    be     mul- 

Always single 

Often 

Occasion- 

Very    rarely 

tiple  or  single 

multiple 

Evidences 
of  previ- 
ous syph- 
ilis 

ally  mul- 
tiple, but 
if  so,  all 
close   to- 
gether 
Signs      of 
tuber  c  u- 
lous   dis- 
ease     in 
lungs    or 
e  1  s  e  - 
where 

multiple 

CHAPTER    XXIII. 
DISEASES    OF   THE    GUMS    AND    JAWS. 


As  the  great  majority  of  the  affections  embraced 
under  this  heading  are  dealt  with  in  detail  in  text- 
books on  Dental  Surgery,  it  is  only  necessary  briefly 
to  touch  upon  them  here. 

Gingivitis,  or  inflammation  of  the  gums,  generally 
occurs  in  association  with  stomatitis  (q.v.),  and  is 
dependent  upon  similar  causes.  These  causes  are 
chiefly  connected  with  the  teeth,  e.g.,  tartar,  pressure 
from  an  ill-fltting  denture,  or  any  condition  which 
involves  want  of  cleanliness  in  the  oral  cavity.  Other 
causes  include  the  action  of  certain  drugs,  notably 
mercury  and  phosphorus;  certain  gastro-intestinal 
disorders  grouped  together  under  the  somewhat  vague 
title  of  "  indigestion  " ;  certain  specific  affections,  such 
as  syphilis,  tubercle  and  actinomycosis;  and  many 
general  conditions,  e.g.,  scurvy,  chronic  renal  disease, 
See.  In  its  early  stages  the  disease  is  characterized 
by  a  condition  of  hypercEmia,  the  gums  being  soft  and 
congested,  and  readily  bleeding  on  pressure.  Ulcera- 
tion may  occur,  and  if  neglected,  the  bone  may  become 
involved,  and  necrosis  result. 

Treatment. — The    first    essential    is    to    remove    the 
cause.      An    astringent    mouth- wash    should    be    pre 
scribed,   containing    such    drugs    as    alum,    myrrh,    oi 
krameria,  in  some  such  proportions  as  the  following  :  — 


B 


Cologne 


51- 

5ss. 

5ss. 
5ss. 
e-r.  i, 


Tr.    kramerise 
Tr.  myrrh. 
Tr.  pyrethri 
Alum 
Thymol 
Saccharin 
Sod.  bicarb. 
Eau  de 

Spir.    vini     rect 
Fiat  coll. 

Sig. :  A  teaspoonful  to  be  added  to   a   wine- 
glassful  of  water,  and  used  as  a  mouth-wash. 


o-j- 


ad. 


to 
5vni 


VI. 

iv. 


DISEASES   OF    THE    GUMS    AND    JAWS  189 

As  in  stomatitis,  potassium  chlorate  has  been  re- 
garded as  a  specific,  and  is  still  so  regarded  by  some, 
though  its  efficacy  is  denied  by  others. 

A  smart  purge  should  be  administered  at  the  outset, 
and  regularity  of  the  bowels  ensured  by  salines 
throughout  the  treatment. 

Pyorrhoea  Alveolaris. — For  a  description  of  this 
condition  a  dental  text-book  should  be  consulted. 

Many  general  disorders  may  trace  their  origin  to  this 
condition,  among  which  may  be  specially  mentioned 
any  septic  condition  of  the  gastro-intestinal  tract.  The 
respiratory  tract  may  be  affected,  or  general  septic 
intoxication  may  follow.  This  subject  is  carefully  dis- 
cussed in  the  last  edition  of  Colyer's  ''  Dental  Surgery 
and  Pathology,"  chap.  xxv. 

Diseases  of  the  bones  of  the  jaws  have  the  same 
general  characteristics  as  were  described  in  dealing 
with  the  diseases  of  bone  generally.  (See  Chapter 
XVII.) 

Acute  osteomyelitis  is  most  common  in  children, 
and  generally  arises  in  connection  with  a  tooth.  The 
inflammation  is  often  very  severe,  and  extensive 
necrosis  may  result.  The  condition  is  more  frequent 
in  the  lower  than  the  upper  jaw. 

Treatment. — ^The  offending  tooth  should  be  first 
removed.  Trismus  is  a  not  infrequent  complication 
which  renders  the  operation  of  extraction  difficult  in 
the  hands  of  any  but  an  expert  extractor.  Free  exit 
must  be  given  for  the  pus,  an  opening  on  the  outside 
of  the  cheek  being  made  if  necessary.  If  necrosis 
occurs,  the  removal  of  the  resulting  sequestrum  will 
be  required  later. 

Syphilis,  Tubercle,  and  Actinomycosis  all  rank 
among  the  rare  affections  of  the  jaws.  When  they 
occur,  they  should  be  treated  on  general  lines  (see 
Chapter  XII).  The  recent  suggestion  with  regard 
to  the  possible  connection  between  phosphorus 
necrosis  and  tuberculosis  is  mentioned  below. 

Phosphorus  Necrosis  (Phossy  Jaw)  is  a  condition 
produced  by  the  action  upon  the  system  of  yellow 
phosphorus.     Red  phosphorus  is  not  poisonous. 

The  disease  was  quite  a  common  occurrence  in 
match  factories  in  the  days  when  yellow  phosphorus 
was  employed  ifi  this  industry.     Since  the  introduction 


190  SURGERY    FOR   DENTAL    STUDENTS 

of  the  harmless  red  phosphorus  in  place  of  the  poison- 
ous yellow  variety,  it  has  become  a  comparatively  rare 
disease.  It  commences  with  ulceration  of  the  gums, 
which  rapidly  spreads  to  the  periosteum  and  bone,  the 
lower  jaw  being  most  frequently  affected.  The  gum 
is  separated  from  the  bone,  the  pus  burrowing  its 
way  underneath  the  periosteum  and  raising  it  up;  the 
bone,  robbed  of  its  periosteum,  undergoes  necrosis. 

It  has  been  suggested  recently  that  the  disease 
above  described  is  really  a  tuberculous  osteomyelitis, 
the  phosphorus  merely  acting  as  a  predisposing  cause. 

Treatment.  — •  Prophylactic  treatment  is  of  the 
greatest  importance,  and  the  main  feature  in  the  pro- 
phylaxis is  the  use  of  red  phosphorus  instead  of  yellow. 

Persons  whose  work  brings  them  constantly  in  con- 
tact with  phosphorus  should  be  submitted  *to  frequent 
medical  and  dental  inspection;  and  at  the  first  sign 
of  stomatitis  or  gingivitis  the  patient  must  discon- 
tinue his  work  with  this  substance,  and  the  stomatitis 
be  treated  with  hydrogen  peroxide.  When  the  disease 
has  already  commenced,  contact  with  phosphorus  must 
be  at  once  discontinued.  In  this  particular  malady, 
the  separation  of  the  sequestrum  is  a  very  slow  pro- 
cess, and  it  is  therefore  wise  to  excise  the  diseased 
portion  of  bone  at  once,  without  waiting  for  the 
sequestrum  to  separate  naturally.  If  the  periosteum 
and  outer  layer  of  bone  are  healthy,  as  is  sometimes 
the  case,  an  endeavour  should  be  made  to  preserve 
them;  where  this  is  possible,  new  bone  is  subsequently 
laid  down,  and  often  quite  an  efficient  mandible  results. 

Simple  Hypertrophy  of  the  Gums  is  a  condition  very 
variable  in  extent.  It  most  commonly  occurs  in 
children  as  a  sessile  overgrowth  of  the  gum  between 
and  around  the  teeth. 

Slight  cases  may  be  treated  by  cauterization  with 
glacial  acetic  acid,  while  the  more  severe  varieties  will 
require  excision. 

Odontomata  — Tumours  or  cysts  connected  with  the 
teeth  are  known  as  odontomes,  and  are  of  various 
kinds.  Many  classifications  have  been  put  forward, 
but  the  following  will  be  found  to  satisfy  all  require- 
ments :  — 

A  Follicular  Odontome,  or  Dentigerous  Cyst,  is 
a   cyst   which    develops    around  a    tooth,    usually  one 


DISEASES   OF    THE    GUMS    AND    JAWS  I9I 

of  the  permanent  series,  especially  in  the  molar  region. 
The  tooth  follicle  becomes  expanded  to  a  variable 
extent,  the  thickness  of  its  wall  varying  from  paper 
thickness  to  a  quarter  of  an  inch  or  so,  according  to  the 
amount  of  expansion  which  takes  place.  The  cyst  thus 
formed  is  unilocular,  and  contains  thick  fluid.  It  also 
contains  a  tooth  which  is  in  some  cases  fully  formed, 
while  in  other  cases  is  so  ill-developed  as  to  be  difficult 
to  recognize.  The  cyst  appears  as  a  smooth,  rounded 
tumour,  which  is  of  slow  growth,  and  painless.  The 
actual  cause  of  the  condition  is  not  yet  fully  under- 
stood. Hopewell-Smith  failed  to  lind  Nasmyth's 
membrane  around  teeth  contained  in  follicular  odon- 
tomes,  and  on  this  account  has  suggested  that  the 
stellate  reticulum  has  degenerated  and  liquefied  to 
form  the  fluid  content  of  the  cyst.  In  rare  cases, 
several  teeth  are  present  in  the  cyst,  which  is  then 
termed  a  compound  follicular  odontonie. 

The  diagnosis  of  a  dentigerous  from  a  dental  cyst 
is  made  chiefly  upon  the  absence  of  one  of  the  per- 
manent teeth.  A  skiagram  may  reveal  the  tooth  inside 
the  cyst. 

Treatment. — An  incision  should  be  made  into  the 
cyst,  of  sufficient  size  to  allow  of  the  removal  of  the 
enclosed  tooth.  The  lining  wall  should  be  well 
scraped  and  cauterized  with  pure  carbolic  acid.  The 
cavity  thus  revealed  should  be  packed  with  sterilized 
gauze  to  insure  healing  from  the  bottom.  The  gauze 
dressing  must  be  frequently  changed,  and  the  cavity 
irrigated  with  hydrogen  peroxide. 

An  Epithelial  Odontome,  or  Fibrocystic  Disease  of 
the  Jaw,  is  a  condition  more  frequently  found  in  the 
mandible  than  the  superior  maxilla.  The  etiology 
has  not  been  definitely  settled;  it  probably  arises  either 
in  connection  with  the  enamel  organ,  or  the  mucous 
membrane  of  the  gum. 

Many  cvsts  are  present,  containing  a  brownish 
mucoid  material,  and  separated  from  one  another  by 
thin  fibrous  septa.  In  some  cases,  these  septa  may 
undergo  subsequent  ossification.  The  collection  of 
cysts  results  in  the  formation  of  a  tumour  which  is 
often  of  great  size,  and  may  be  difficult  to  distinguish 
from  myeloid  sarcoma  in  the  early  stages.  After  a 
time,  an  epithelial  odontome  may  become  malignant 
in  character. 


192  SURGERY    FOR    DENTAL    STUDENTS 

The  treatment  consists  in  excision  of  the  portion  of 
the  jaw  involved  by  the  growth. 

A  Fibrous  Odontome  results  from  a  fibrous  thicken- 
ing of  the  tooth  sac,  from  which  the  tooth  never 
emerges.  In  appearance,  the  resulting  tumour  re- 
sembles a  hbroma.  It  is  rare  in  man,  but  fairly 
common  in  the  lower  animals,  especially  in  goats. 
When  occurring  in  man,  it  should  be  removed. 

A  Cementoma  is  also  a  condition  rare  in  man,  but 
fairly  common  in  horses.  The  tooth  becomes  em- 
bedded in  a  mass  of  cementum,  which  may  attain 
coiisiderable  size.     The  tumour  should  be  removed. 

A  Radicular  Odontome  is  a  tumour  attached  to  the 
root  of  a  tooth.  It  makes  its  appearance  after  the 
crown  is  formed,  but  during  the  formation  of  the  root. 
It  consists,  therefore,  of  dentine  and  cementum,  but 
not  enamel.  Unlike  other  odontomata,  it  often  causes 
considerable  pain. 

Treatment  consists  in  extraction  of  the  tooth  with 
the  attached  growth. 

A  Composite  Odontome  is  a  tumour  formed  from  all 
the  elements  of  a  tooth  germ.  It  frequently  first 
attracts  attention  at  about  twenty  years  of  age,  form- 
ing a  hard  tumour,  often  of  considerable  size.  The 
maxillary  antrum  is  frequently  involved  in  the  growth. 
Occasionally  suppuration  occurs. 

Treatment. — The  tumour  should  be  removed. 

A  Dental  Cyst  is  formed  in  connection  with  a  diseased 
tooth,  which  is  almost  invariably  dead.  It  is  a  uni- 
locular cyst,  lined  with  epithelium.  It  does  not  contain 
a  tooth.  Clinically,  it  closely  resembles  a  dentigerous 
cyst;  the  two  conditions  are  frequently  mistaken  for 
one  another,  until  operative  treatment  reveals  the  true 
nature  of  the  tumour. 

Treatment. — The  cyst  should  be  opened,  the  epithe- 
lial lining  scraped,  and  cauterized  with  pure  carbolic, 
and  the  cavity  of  the  cyst  packed  with  sterilized  gauze, 
the  dressing  being  frequently  changed. 

Epulis  is  a  tumour  arising  from  the  alveolar  peri- 
osteum or  the  periodontal  membrane.  It  may  be 
simple  or  malignant. 

A  simple  epulis  is  a  fibroma,  frequently  associated 
with  a  diseased  tooth.  It  forms  a  somewhat  hard, 
pink   tumour,    with   a    smooth,    or   sometimes    slightly 


DISEASES    OF    THE    GUMS    AND    JAWS  I93 

irregular  surface.  A  tumour  of  this  type,  which  has 
been  present  for  some  time,  may  undergo  ulceration. 

Treatment. — The  growth  should  be  removed.  In 
most  cases  it  is  necessary  to  remove  part  of  the  bone 
of  the  jaw  with  the  tumour,  but  the  jaw  rarely  needs 
to  be  cut  right  through. 

-Malignant  epulis  is  a  term  somewhat  loosely  used. 
Sometimes  it  is  applied  to  all  malignant  tumours  of  the 
jaw,  while  in  other  cases  it  is  used  to  mean  a  myeloid 
sarcoma  (q.v.). 

Carcinoma  and  Sarcoma  both  occur  in  the  jaws, 
having"  the  characteristics  of  malignant  tumours  gener- 
ally. The  diseases  are  treated  by  excision  of  the 
affected  parts  and  the  neighbouring  glands. 

Osteomata  of  the  upper  jaw  have  been  described  by 
some  observers.  It  seems  probable  that  these  tumours 
were  in  reality  composite  odontomes. 

Leontiasis  Ossea  is  a  very  slow-growing,  diffuse 
enlargement  of  the  bone  of  the  upper  jaw.  The  cranial 
bones  are  also  sometimes  affected.  It  causes  no  sym- 
ptoms except  those  due  to  pressure. 

Treatment. — Where  pressure  symptoms  occur,  and 
the  position  of  the  tumour  allows  of  operative  inter- 
ference, the  growth  should  be  chiselled  away. 


13 


CHAPTER  XXIV. 
DISEASES  OF  THE  NOSE. 

Rhinitis  denotes  inflammation  of  the  nasal  mucous 
membrane,  many  varieties  of  which  are  described. 
Only  a  few  of  the  more  important  ones  can  be  dealt 
with  here. 

Acute  Catarrhal  Rhinitis  is  a  condition  commonly 
known  as  a  cold  in  the  nose.  The  nasal  mucous  mem- 
brane is  affected  by  a  catarrhal  inflammation,  which 
results  in  a  watery  nasal  discharge,  accompanied  by 
the  well-known  symptoms,  sneezing,  headache,  fever, 
&c.  These  symptoms,  especially  the  fever,  vary  con- 
siderably in  severity  in  different  cases.  Laryngitis  or 
bronchitis  are  frequently  present  in  addition,  giving 
rise  to  further  symptoms,  of  which  cough  is  the  most 
noticeable. 

The  disease  is  bacterial  in  origin;  several  varieties 
of  organisms  are  present  as  a  rule,  among  which 
Micrococcus  catarrhalis,  Pneutnococcus,  and  Bacillus 
influenzie  may  be  mentioned  as  examples. 

An  unpleasant,  but  by  no  means  rare,  complication 
is  the  extension  of  the  inflammation  to  one  or  more  of 
the  accessory  sinuses,  the  frontal  and  ethmoid  being 
most  frequently  involved.     {See  Chapter  XXV.) 

Treatment. — Every  mother  has  her  own  infallible 
remedy  for  a  cold.  And  as  most  colds  will  get  well 
without  treatment,  the  infallibility  of  the  home-made 
nostrum  is  rarely  called  in  question. 

The  chief  point  to  be  borne  in  mind  in  treating  a 
cold  is  that  it  is  an  infective  disease.  Measures  should 
therefore  be  directed  towards  the  destruction  of  the 
micro-organisms.  This  may  be  achieved  in  various 
ways. 

The  patient's  own  power  of  resistance  to  the  micro- 
organisms should  be  kept  as  strong  as  possible,  all 
available  means  being  taken  to  avoid  any  lowering  of 
this  resisting  power.  The  patient  should  be  kept  in 
bed,  and  milk  diet  prescribed  as  long  as  the  tempera- 
ture is  raised.  The  bowels  must  be  regulated  by  suit- 
able pur.s^atives.  Local  means,  such  as  spraying  the 
nose   with   very   weak    formalin    solution  (e.^.,    I  per 


DISEASES    OF    THE    NOSE  195 

cent.)  is  strongly  advocated  by  some.  Formalin,  how- 
ever, is  an  irritating  drug,  and  when  applied  to  an 
already  inflamed  mucous  membrane,  sometimes  does 
more  harm  to  the  tissues  than  to  the  bacteria. 

Another  way  of  giving  the  drug  is  in  the  form  of 
formamint  lozenges.  Certain  drugs  are  credited  with 
a  specific  action  in  these  cases.  Both  sodium  salicylate 
and  aspirin  in  20-gr.  doses  three  times  a  day 
are  certainly  of  value,  while  six  grains  of  quinine  at 
bedtime  at  the  beginning  of  a  cold  will  often  cut  short 
its  career  forthwith.  If  the  cough  is  severe,  Dover's 
powder  gr.  x  may  be  given  at  bedtime.  For  a  detailed 
description  of  this  condition,  a  text-book  on  medicine 
should  be  consulted. 

Acute  Suppurative  Rhinitis  may  occur  in  the  course 
of  an  acute  specific  fever,  e.g.,  scarlet  fever;  by  exten- 
sion from  an  empyema  of  one  of  the  accessory  sinuses; 
or  occasionally  it  may  be  gonorrhoeal. 

The  nose  should  be  frequently  washed  out  with  weak 
boracic  acid  lotion,  and  the  nasal  mucous  membrane 
painted  with  silver  nitrate  solution  gr.  v  ad    ^i. 

Diphtheria  may  affect  the  nose.     (See  p.   175.) 

Chronic  Catarrhal  Rhinitis  usually  results  from  a 
neglected  acute  attack.  It  is  frequently  associated 
with  some  chronic  nasal  obstruction,  such  as  adenoids, 
enlarged  tonsils,  a  deflected  nasal  septum,  or  hyper- 
trophied  inferior  turbinate  bone. 

Clinically,  it  is  characterized  by  the  presence  of  a 
mucopurulent  discharge,  while  the  anterior  end  of  the 
inferior  turbinate  looks  soft,  flabby  and  oedematous. 
Any  previous  nasal  obstruction  is  aggravated  by  the 
condition. 

Treatment. — The  nose  should  be  frequently  washed 
out  with  an  alkaline  lotion,  such  as  :  — 

B  Sod.    bicarb.    ...  ...         ...         ...         5i. 

Boracis  ...  ...         ...         ...         5i. 

Acid   carbol.    ...  ...  ...         ...         ttixx. 

Aquam  ...  ...  ...         ...ad.jviii. 

Fiat  coll. 

Sig. :  To   be   diluted  with  an   equal   quantity 
of  water  and  used  as  a  nasal  wash. 

The  anterior  end  of  the  inferior  turbinate  should  be 
removed,  if  enlarged ;  and  any  adenoids  or  any  deflec- 
tions of  the  septum  dealt  with. 


196  SURGERY    FOR   DENTAL    STUDENTS 

Chronic  Hypertrophic  Rhinitis. — In  this  disease  the 
nasal  mucous  membrane  and  the  turbinate  bones  are 
hypertrophied,  and  unduly  pale  in  colour.  The  con- 
dition gives  rise  to  a  stuffed-ug  feeling  in  the  nose, 
sneezing,  and  watery  nasal  discharge.  The  sense  of 
smell  is  commonly  impaired,  while  the  blocking  of  the 
Eustachian  tube  by  hypertrophied  mucous  membrane 
or  by  discharge  often  results  in  impairment  of  hearing 
also. 

TreaUnent. — A  warm  alkaline  lotion  should  be  used 
to  wash  out  the  nose.  This  must  be  done  constantly 
and  carefully.  If  necessary,  the  mucous  membrane 
may  be  cauterized  with  the  actual  cautery  under 
cocaine,  or  the  anterior  end  of  the  inferior  turbinate 
may  be  removed.  Smoking  should  be  reduced  to  a 
minimum,  and  attempts  made  to  improve  the  general 
health  by  purgation,  tonics,  exercise  in  the  fresh  air, 
&c. 

Rhinitis  Sicca  is  a  condition  in  which  there  is  a 
deficiency  of  nasal  secretion;  the  mucous  membrane  is 
dull,  red  and  dry,  and  covered  with  dried  crusts.  There 
is  also  some  dryness  of  the  throat,  and  frequently  an 
irritating  cough. 

Constant  washing  out  with  warm  alkaline  lotions  is 
the  chief  point  in  the  treatment.  A  potassium  chlorate 
gargle  may  also  be  given. 

Chronic  Atrophic  Rhinitis,  or  Ozsena,  as  it  is  some- 
times termed,  is  an  extremely  disgusting  complaint  in 
which  atrophy  of  the  nasal  mucous  membrane  occurs, 
accompanied  by  a  foetid  discharge,  which  forms  large 
crusts  of  inspissated  mucus. 

One  of  the  main  features  of  the  disease  is  an  ex- 
tremely offensive  odour,  quite  characteristic  to  those 
familiar  with  it;  the  patient  is  entirely  unaware  of  the 
presence  of  this  unpleasant  smell.  The  malady  may 
be  accompanied  by  a  dry  cough,  slight  headache,  and 
sometimes   slight  epistaxis   {see  p.    197). 

TreaUnent  consists  in  thoroughly  cleaning  out  the 
nasal  passages.  An  alkaline  lotion  must  be  given,  but 
the  crusts  require  to  be  gently  removed  by  means  of 
dressing  forceps.  It  will  be  necessary  to  persevere 
with  this  treatment  for  a  considerable  period. 

Adenoids  {see  p.  180). 

Nasal  Polypi  are  soft,  red,  pedunculated  growths, 
occurring  in  the  nose.     They  are  composed  chiefly  of 


DISEASES    OF    THE    NOSE  IQ/ 

myxomatous  tissue,  and  are  frequently  multiple.  They 
depend  upon  disease  of  the  underlying  bone,  usually 
the  ethmoid  bone. 

The  main  symptoms  they  cause  are  nasal  obstruction 
and  increased  mucous  discharge. 

-  Treatment. — The    growths    should    be    removed    by 
means  of  a  wire  snare. 

Lupus  (vide  p.  223). 

Syphilis  (vide  p.  91). 

Rodent  ulcer  (vide  p.  222). 

Malignant  disease  of  the  nose  is  uncommon  apart 
from  rodent  ulcer.  Sarcoma  is  rather  more  common 
than  carcinoma. 

Epistaxis,  or  nose  bleeding,  may  result  from  local 
or  general  causes. 

The  most  frequent  local  causes  are: — Injury  (see 
Fracture  of  base  of  skull,  p.  123),  foreign  bodies  in  the 
nose,  polypus,  adenoids,  chronic  rhinitis,  or  ulceration 
from  tubercle,  syphilis,  or  malignant  disease. 

Some  of  the  more  important  general  diseases  of 
which  epistaxis  may  be  a  manifestation  are  :  Diseases 
of  the  blood,  e.g.,  anaemia,  purpura,  or  scurvy;  in- 
creased blood-pressure,  e.g.,  in  renal  disease;  obstruc- 
tion to  the  return  of  blood  to  the  heart,  e.g.,  in  certain 
cardiac  diseases,  or  in  cirrhosis  of  the  liver;  or  in 
haemophilia.  It  also  frequently  occurs  in  boys  for  no 
apparent  reason,  and  appears  to  have  quite  a  beneficial 
effect  upon  their  health. 

Treatment. — It  w411  be  obvious  that  the  treatment 
must  depend  very  much  upon  the  cause.  In  certain 
conditions  the  haemorrhage  may  be  beneficial,  and 
should  not  be  hastily  controlled. 

Epistaxis  due  to  local  causes  is  generally  slight.  The 
patient  should  lie  down  on  his  back;  the  worst  possible 
treatment  is  to  bend  over  a  basin.  The  application  of 
ice-cold  water  to  the  nape  of  the  neck  is  often  sufficient 
to  stop  the  bleeding.  If  this  measure  fails,  the  meatus 
of  the  nose  must  be  carefully  examined  by  means  of  a 
nasal  speculum  and  head  mirror.  A  useful  nasal 
speculum  can  be  improvised  out  of  a  hairpin  by  bend- 
ing the  two  ends  sideways  into  hooks.  It  will  very 
often  be  found  on  examination  that  the  bleeding  comes 
from  the  small  artery  to  the  septum.  The  bleeding 
spot  will  then  be  found  about  half  an  inch  behind  the 
anterior  edge  of  the  septal  cartilage.     The  application 


198  SURGERY    FOR   DENTAL    STUDENTS 

of  cocaine,  followed  by  the  actual  cautery,  to  this  spot 
will  at  once  stop  the  haemorrhage.  Solid  silver  nitrate 
will  often  prove  equally  successful. 

Any  of  the  causes  mentioned  above  should  be  dealt 
with  as  far  as  possible,  if  present. 

Severe  epistaxis  is  not  common,  and  is  generally 
due  to  some  general  cause.  Plugging  the  nostril  with 
cottonwool  soaked  in  i  in  1000  adrenalin  solution  will 
usually  stop  it.  Several  mechanical  devices  for  plug- 
ging the  posterior  nares  have  been  used,  but  the 
epistaxis  is  rarely  of  sufficient  severity  to  require  such 
methods. 

Foreign  Bodies  in  the  Nose.— Children  often  push 
things  up  their  nose  a  little  too  far  for  them  to  reach. 
Subsequent  efforts  to  dislodge  the  object  with  a  pin 
or  other  handy  instrument  usually  result  in  pushing  it 
further  up. 

When  the  child  is  brought  with  a  definite  history  of 
having  pushed  something  up  his  nose  the  diagnosis  is 
already  made.  But  very  often  the  child,  from  fear  or 
some  other  reason,  does  not  tell  his  parents  what  he 
has  done.  The  foreign  body  then  remains  in  the  nose, 
and  from  the  irritation  of  its  continued  presence  a  local 
inflammation  results.  The  child,  therefore,  is  often 
brought  to  be  treated  for  discharge  from  the  nose, 
without  any  hint  of  its  cause  being  given.  In  this 
connection,  it  must  be  remembered  that  a  unilateral 
nasal  discharge  in  a  child  is  almost  invariably  due  to 
the  presence  of  a  foreign  body. 

The  treatment,  of  course,  is  to  remove  the  foreign 
body.  This  is  by  no  means  so  simple  as  it  sounds. 
The  nose  must  be  carefully  examined  with  the  aid  of 
speculum  and  head  mirror,  and  the  position  and  shape 
of  the  object  determined.  No  attempt  must  ever  be 
made  to  seize  the  object  with  forceps  and  pull  it  out. 
This  is  a  temptation  difficult  to  resist,  for  it  looks  so 
easy.  But  the  result  almost  always  is  that  the  object, 
especially  a  smooth,  round  thing,  such  as  a  marble, 
slips  out  of  the  forceps,  and  passes  still  further  along 
the  meatus,  the  difficulty  of  removal  being  thus  con- 
siderably increased. 

The  best  method  to  employ  is  to  pass  a  hooked  in- 
strument up  the  nose  past  the  foreign  body,  and  then 
drazi'  it   downwards.     By   this   means   the    removal   is 


CHAPTER  XXV. 
DISEASES  OF  THE  ACCESSORY  SINUSES. 

A  CLEAR  and  precise  knowledge  of  anatomy  is  an 
essential  preparation  to  the  study  of  surgery  in  all  its 
branches;  and  the  accessory  air  sinuses  of  the  face  are 
no  exception  to  this  rule.  The  maxillary  and  in  less 
degree  the  frontal  sinuses  are  more  intimately  con- 
nected with  dental  disease,  and  it  is  with  the  diseases 
of  these  cavities  that  this  chapter  chiefly  deals. 

Our  knowledge  of  the  normal  anatomy  of  the  maxil- 
lary sinus,  known  familiarly  as  "the  antrum,"  has 
quite  recently  undergone  considerable  alteration,  and 
it  would  be  well  for  the  student  to  render  himself 
familiar  w4th  the  revised  views  concerning  the 
anatomical  relations  of  the  sinus  which  have  been 
approved  by  modern  scientific  authorities."^ 

One  important  anatomical  consideration  which  must 
never  be  lost  sight  of  in  dealing  with  disease  of  any  of 
the  air  sinuses,  is  that  the  mucous  membrane  lining  all 
these  cavities,  and  also  the  meatus  of  the  nose,  is 
one  continuous  layer,  which  explains  in  some  measure 
the  readiness  with  which  infection  may  spread  from  the 
nose  to  an  air  sinus,  or  from  one  sinus  to  another. 

Maxillary  Sinus  (Antrum  of  Highmore). 

Acute  Catarrhal  Inflammation  occurs  mostly  as  the 
result  of  nasal  catarrh,  and  is  frequently  associated 
with  a  similar  inflammation  of  one  or  more  of  the  other 
air  cells.  In  addition  to  the  symptoms  dependent  on 
tlie  nasal  catarrh,  the  patient  experiences  a  sense  of 
fullness  and  dull  pain  in  the  region  of  the  antrum.  The 
pain  is  sometimes  neuralgic  in  type,  spreading  along 
the  branches  of  the  fifth  cranial  nerve. 

Severe  pain  over  the  eyes,  localized  at  the  supra- 
orbital notch,  is  a  common  symptom  of  antral  mischief, 
and  must  not  be  thought  to  be  pathognomonic  of 
frontal  sinus  disease. 

*  Underwood,  A.  S.     /oicrn.  of  Aiiat.  and  Fhys.,  1910. 


200  SURGERY    FOR    DENTAL    STUDENTS 

Treatment. — The  nasal  catarrh  must  be  treated  in  the 
manner  ah-eady  described  (p.  194).  Local  treatment 
consists  in  washing  out  the  nose  and  applying  a 
solution  of  cocaine  and  adrenalin  around  the  opening 
from  the  antrum  into  the  nose.  This  procedure  helps 
to  reduce  the  swelling  of  the  mucous  membrane,  and 
allow  free  exit  to  fluid  in  the  antrum.  If  necessary, 
the  anterior  end  of  the  inferior  turbinate  must  be 
removed.  If  no  fluid  comes  out,  a  probe  should  be 
passed  in  through  the  opening*.  Fomentations  may  be 
applied  externally.  Antiphlogistine  is  a  very  useful 
application. 

Acute  Suppuration  in  the  Maxillary  Sinus  (Acute 
Antral  Empyema)  frequently  results  from  disease  of  the 
molar  teeth,  the  frequency  decreasing  as  you  go  for- 
wards. 

There  is  so  much  misunderstanding  prevalent  with 
regard  to  the  liability  of  particular  teeth  to  be  involved 
in  antral  disease  that  it  will  be  w^ell  to  state  the  facts 
clearly  once  and  for  all.  The  third  molar,  or  wisdom 
tooth,  is  always  in  intimate  relation  with  the  cavity; 
the  second  molar,  first  molar  and  second  premolar, 
are  associated  in  degree  of  frequency  in  the  order 
named;  the  first  premolar  is  rarely  concerned  with 
antral  disturbance,  the  canine  practically  never,  and 
the  teeth  m  front  of  the  canine  only  as  pathological 
curiosities. 

Antral  empyema  may  also  occur  as  a  sequel  of  the 
acute  catarrhal  form,  or  of  some  septic  condition  in  the 
throat,  or  may  result  from  injury,  e.g.,  the  extraction 
of  a  tooth  with  surgically  dirty  forceps. 

The  exact  proportion  of  ''throat"  origins  for 
empyema  as  compared  with  "  tooth  "  origins  cannot 
be  stated  dogmatically — experts  differ. 

In  the  opinion  of  the  authors,  the  starting-point  of 
the  trouble  is  much  more  frequently  the  throat,  and 
the  pure  "  tooth  ''  cases  do  not  account  for  more,  at  a 
liberal  estimate,  than  one-third. 

Clinically,  the  condition  resembles  the  catarrhal 
form,  but  is  accompanied  by  a  unilateral  purulent  nasal 
discharge.  The  pain  is  sometimes  severe,  with  tender- 
ness on  pressure.     There  may  be  some  fever. 

Transillumination  is  a  physical  sign  which  is  some- 
times of  great  value,  but,  on  the  other  hand,  may  be 


DISEASES    OF    THE    ACCESSORY     SINUSES  201 

quite  misleading'.  A  definite  difference  in  the  condition 
of  the  two  sides,  on  transihumination,  is  very  sugges- 
tive of  the  presence  of  pus  in  the  antrum,  but  cannot 
be  regarded  as  a  certain  sign. 

Puncture  of  the  antrinn  through  the  nose  is  very- 
useful,  as  it  serves  both  as  an  aid  to  diagnosis  and  a 
means  of  treating  the  condition  if  present.  If  on 
puncturing  the  antrum  and  washing  it  out  pus  is  ob- 
tained, the  diagnosis  is  rendered  certain.  If  no  pus  is 
obtained  in  this  way,  antral  empyema  cannot  be  ex- 
cluded, as  there  may  exist  in  the  antrum  septa  so 
placed  that  a  collection  of  pus  behind  a  septum  is  not 
reached  by  the  exploring  cannula. 

Treatment. — In  cases  of  dental  origin,  the  offending 
tooth  should  be  extracted.  In  acute  cases  cure  often 
results  from  washing  out  the  cavity  intranasally 
through  a  cannula,  as  described  above. 

It  will  be  necessary  to  perform  this  operation  at  least 
three  or  four  times.  If  on  the  fourth  occasion  no  pus 
is  obtained,  the  disease  may  be  said  to  be  cured. 

If  this  treatment  should  fail  more  radical  measures 
must  be  adopted,  as  described  in  dealing  with  the 
chronic  variety. 

Chronic  Antral  Empyema  usually  follows  the  acute 
variety,  but  may  be  chronic  from  the  first.  It  may  be 
due  to  any  of  the  causes  from  which  the  acute  cases 
result. 

The  clinical  aspect  of  chronic  antral  empyema  is 
similar  to  the  acute  type.  Definite  signs  of  distension 
of  the  cavity  may  be  made  out;  a  tender  swelling  may 
be  detected  pressing  outwards  in  the  cheek,  inwards  in 
the  nose,  or  downwards  in  the  palate. 

The  most  prominent  symptom,  however,  is  chronic 
unilateral  purulent  nasal  discharge.  This  discharge 
may  pass  forv/ards  to  make  its  appearance  on  the  hand- 
kerchief, or  backwards  when  it  is  swallowed,  and 
causes  an  unpleasant  taste.  Transillumination,  and 
puncture  through  the  nose  are  valuable  aids  in  the 
diagnosis. 

Treatment. — In  all  cases  of  dental  origin  the  offend- 
ing tooth  must  be  removed,  and  this  treatment  quite 
often  ends  the  whole  trouble.  This  necessary  proce- 
dure leaves  a  tempting  opening  into  the  antrum  ready 
to  hand,  through  which  lavage  of  the  cavity  might  be 


202  SURGERY    FOR    DENTAL    STUDENTS 

undertaken.  But  the  temptation  to  make  use  of  this 
means  of  access  to  the  cavity  must  be  resisted  at  all 
costs.  The  dangers  of  sepsis  by  which  it  is  accom- 
panied are  sufficient  to  condemn  the  method  out  of 
hand. 

On  the  other  hand,  a  simple  puncture  through  the 
nose  will  probably  be  required  to  clinch  the  diagnosis, 
and  treatment  can  be  commenced  by  washing  out  the 
cavity  by  this  means.  In  chronic  cases,  however,  and 
in  some  acute  cases,  more  drastic  operative  measures 
are  required.  The  anterior  end  of  the  inferior  tur- 
binate bone  may  be  removed,  and  the  inner  wall  of  the 
antrum  broken  away,  so  as  to  leave  a  large,  permanent 
intranasal  opening  through  which  lavage  can  be  per- 
formed. 

In  still  more  obstinate  cases  a  radical  operation  is 
required;  the  variety  most  frequently  undertaken  is 
that  known  as  the  Caldwell-Luc  operation.  An  incision 
about  an  inch  in  length  is  made  over  the  region  of  the 
canine  fossa,  at  the  junction  of  the  buccal  and  alveolar 
mucous  membrane.  The  incision  is  continued  right 
down  to  the  bone.  The  periosteum  is  then  stripped 
off  the  bone,  both  upwards  and  downwards,  leaving 
uncovered  the  bone  composing  the  anterior  wall  of  the 
antrum.  This  bony  wall  is  then  chiselled  away  suffi- 
ciently to  admit  the  surgeon's  finger.  The  cavity  is 
carefully  explored,  and  all  pus  or  polypi  removed. 
Septa  behind  which  pus  may  be  lodging  should  be 
broken  down.  As  far  as  possible  the  lining  membrane 
of  the  cavity  should  be  left  intact. 

The  cavity  having  been  fully  explored  and  cleansed, 
a  large  permanent  opening  is  made  in  the  inner  wall 
of  the  antrum  leading  into  the  inferior  meatus  of  the 
nose.  The  wound  in  the  mucous  membrane  covering 
the  canine  fossa  is  then  closed  by  stitches.  Constant 
irrigation  of  the  cavity  will  be  subsequently  required 
for  a  few  days. 

Tumours  of  the  Antrum. — Polypi  are  the  most  com- 
mon simple  tumours,  and  should  be  removed;  they 
.L^'enerally  occur  in  connection  with  chronic  empyema 
(q.'v.). 

Both  carcinoma  and  sarcoma  may  affect  the  antrum. 
The  operative  measures  necessary  for  the  removal  of 


DISEASES    OF    THE    ACCESSORY     SINUSES  203 

malignant  growths  in  this  region  are  commonly  very 
extensive. 

Frontal  Sinus. 

The  same  varieties  of  inflammatory  affections  occur 
as  have  been  described  in  dealing  with  diseases  of  the 
maxillary  sinus. 

Acute  Catarrh  occurs  in  the  course  of  nasal  catarrh, 
or  catarrh  of  other  sinuses,  and  gives  rise  to  unilateral 
frontal  headache,  with  tenderness  on  pressure  above 
the  eye. 

Treatment. — The  accompanying  nasal  catarrh  must 
be  dealt  with.  The  application  of  Antiphlogistine  or 
a  blistering  agent  to  the  skin  over  the  sinus  constitutes 
most  effective  local  treatment. 

Acute  Suppuration  usually  results  from  injury  or 
extension  of  inflammation  from  the  nose  or  neighbour- 
ing sinuses.  It  is  characterized  by  a  unilateral  puru- 
lent nasal  discharge,  which  may  be  seen  to  come  from 
the  opening  of  the  infundibulum. 

An  attempt  may  be  made  to  pass  a  probe  into  the 
cavity  through  the  infundibulum.  This  is  an  operation 
which  requires  considerable  experience  and  skill.  It 
is  rendered  somewhat  easier  by  the  removal  of  the 
anterior  end  of  the  inferior  turbinate.  Lavage  of  the 
cavity  has  been  carried  out  through  the  infundibulum. 

In  most  cases  radical  measures  are  required.  The 
operation  usually  undertaken  is  known  as  Killian's 
operation.  An  opening  in  the  anterior  wall  of  the 
sinus  is  made  through  an  incision  in  the  line  of  the 
eyebrow,  and  the  cavity  irrigated. 

Chronic  Frontal  Sinus  Empyema  Is  treated  by  the 
same  methods  as  the  acute  variety. 

Tumours  of  the  Frontal  Sinus — 

Polypi  are  the  most  frequent  simple  tumours  which 
occur.  They  rarely  cause  symptoms,  and  consequently 
escape  both  diagnosis  and  treatment. 

Careinoma  and  Sarcoma  usually  occur  by  extension 
from  surrounding  tissues. 


CHAPTER  XXVI. 
DISEASES  OF  THE  SALIVARY  GLANDS. 

Parotid  Gland. 

Acute  Parotitis  may  result  from  injury  or  exposure 
to  cold;  from  extension  of  inflammatory  conditions  of 
the  mouth  or  teeth,  such  as  stomatitis  or  alveolar 
abscess;  or  as  a  complication  of  an  acute  specific  fever, 
especially  typhoid  or  scarlet  fever.  The  disease  is 
characterized  by  a  painful  swelling  of  the  gland,  which 
is  tender  to  pressure;  there  is  usually  some  redness  of 
the  skin,  and  oedema  of  the  superficial  tissues  covering 
the  gland.  When  the  inflammation  progresses  as  far 
as  the  stage  of  suppuration,  the  pus  commonly  burrows 
\y  deeply,  as  the  tenseness  of  the  superficial  tissues  in  this 
region  tends  to  prevent  the  abscess  from  pointing 
immediately  over  the  gland. 

Severe  constitutional  disturbance  often  accompanies 
the  condition. 

Treatment. — In  the  early  stages,  fomentations  should 
be  applied.  When  suppuration  occurs,  the  pus  should 
be  evacuated  by  operation.  The  incision  should  be  so 
planned  that  the  least  possible  injury  be  done  to  the 
branches  of  the  facial  nerve. 

Chronic  Parotitis  may  follow  the  acute  variety,  or 
may  result  from  the  impaction  of  a  calculus  in  Sten- 
son's  duct.  A  chronic  painful  swelling  results,  which 
may  suppurate.  The  condition  should  be  treated  in 
the  same  way  as  the  acute  variety. 

Epidemic  Parotitis,  or  Mumps,  belongs  more  to  the 
domain  of  medicine  than  of  surgery,  and  is  conse- 
quently not  considered  here. 

Tumours  of  the  Parotid  Gland. 

The  so-called  Parotid  Tumour  is  most  probably  an 
endothelioma,  but  the  tissues  of  which  it  is  composed 
are  various.  It  forms  a  hard,  firm,  nodular  tumour, 
which  is  painless  and  grows  very  slowly.     At  first  it  is 


DISEASES    OF    THE    SALIVARY    GLANDS  20$ 

adherent  neither  to  the  skin  nor  to  underlying  struc- 
tures, and  is  therefore  somewhat  movable,  but  later 
on  it  tends  to  become  tixed.  Mucoid  degeneration 
may  occur,  resulting  in  the  presence  of  soft  areas  scat- 
tered through  the  hard  tumour.  If  left  untreated,  it 
tends  to  become  malignant. 

Treatment. — On  account  of  this  tendency  to  take  on 
malignant  characteristics,  the  growth  should  be  com- 
pletely removed.  The  operation  involves  difficult  dis- 
section in  order  to  avoid  injury  to  important  structures. 

Carcinomata  and  Sarcomata  occur  in  the  parotid 
gland.  These  tumours  should  be  completely  removed 
with  the  neighbouring"  lymphatic  glands. 

Wounds  of  Stenson's  Duct  are  tmcommon,  except 
as  the  result  of  operative  procedure.  The  severed  ends 
of  the  duct  should,  if  possible,  be  sutured  together.  If 
this  cannot  be  done,  an  incision  should  be  made, 
through  the  buccal  mucous  membrane,  and  the  upper 
•end  of  the  duct  (that  is,  the  end  nearest  the  gland) 
sutured  to  the  margins  of  this  incision,  so  that  the 
salivary  fistula,  when  formed,  may  open  into  the  mouth 
and  not  towards  the  exterior. 

Salivary  fistula  is  fairly  common  in  connection  with 
Stenson's  duct,  but  rarely  affects  the  other  salivary 
glands  or  ducts.  It  may  result  from  a  Avound  (opera- 
tive, as  a  rule)  or  destruction  by  disease.  A  small 
opening  is  formed,  from  which  saliva  is  discharged, 
this  discharge  being  naturally  increased  at  meal-times. 
Ingenious  operative  measures  have  been  devised  by 
which  the  fistula  may  be  made  to  discharge  into  the 
buccal  cavity,   instead  of  externally. 

Submaxillary  Gland. 

The    inflammatory    affections    of    the    submaxillary 
gland  are  similar  to  those  which  affect  the  parotid,  and  v^ 
result  from  similar  causes.       Submaxillary  mumps  is 
extremely  rare. 

Tumours  of  the  submaxillary  gland  are  rare. 


CHAPTER    XXVII. 
DISEASES    OF    THE    LARYNX. 

Acute  Laryngitis  may  result  from  a  great  variety  of 
causes,  of  which  the  following  are  the  most  im- 
portant :  — 

(i)  By  extension  of  inflammation  from  the  nose  or 
nasopharynx  in  catarrh  of  these  regions. 

(2)  During  the  course  of  an  acute  specific  fever  (e.g.. 
influenza,  measles,  small-pox,  &c.). 

(3)  From  trauma  (e.g.,  a  foreign  body  or  a  scald). 

(4)  From  the  inhalation  of  irritant  fumes  (e.g.. 
tobacco  smoke,  bromine,  &c.). 

(5)  From  over-use  of  the  voice,  in  singing  or  public 
speaking. 

The  disease  commences  with  dryness  and  irritation 
in  the  larynx,  accompanied  by  a  dry  cough.  Later  on, 
clear  mucus  is  coughed  up  which  may  become  muco- 
purulent. Hoarseness  is  usually  a  prominent  symptom, 
while  there  may  be  some  pain  in  deglutition.  In  severe 
cases,  especially  in  children,  dyspnoea  may  occur,  and 
may  become  urgent. 

On  laryngoscopic  examination,  which  is  very  difficult 
to  any  but  those  constantly  practising  it,  the  vocal 
cords  and  surrounding  mucous  membrane  will  be  found 
to  be  swollen  and  hyper^mic :  the  epiglottis  also  may 
be  similarly  affected. 

Treatment. — Any  of  the  irritant  causes  mentioned 
above  must  be  removed,  if  present.  Absolute  rest  is 
an  essential  in  the  treatment.  The  patient  should  be 
kept  in  bed,  and  absolutely  forbidden  to  use  his  voice 
in  any  way.  Steam  from  a  bronchitis  kettle,  to  which 
tinct.  benzoinae  co.  5i  has  been  added,  may  give 
relief;  or  the  same  quantity  of  the  compound  tincture 
may  be  added  to  boiling  water  and  inhaled  direct.  A 
cold  compress  applied  to  the  throat  may  be  of  value. 
Saline  purges  should  be  ,c:iven  as  required,  and  a  light 
diet,  chiefly  consisting  of  milk,  is  suitable.  A  simple 
expectorant  mixture  should  be  prescribed  for  the 
cough,  such  as  the  following :  — 


DISEASES    OF    THE    LARYNX 

U.  Liq.   amnion,   acetat. 

... 

5ii- 

Vin.  ipecac. 

5SS. 

Syr.  tolut. 

5i- 

Aq.  chloroformi    ... 

'.'.'.  ad. 

5i- 

Fiat  mist. 

Sig.  ji.  three  times  a  day. 

207 


In  the  case  of  children,  in  whom  dyspnoea  is  urgent, 
an  emetic  should  be  administered.  For  this  purpose, 
vin.  ipecac.  5i  may  be  given  two  or  three  times  at 
intervals  of  an  hour  or  less,  until  emesis  results.  In 
very  severe  cases,  it  may  be  necessary  to  perform 
tracheotomy. 

Chronic  Laryngitis  occurs  in  various  forms.  It  may 
follow  an  acute  attack,  especially  if  several  previous 
acute  attacks  have  occurred.  Any  of  the  causes  men- 
tioned under  acute  laryngitis  may,  if  acting  less  vio- 
lently but  for  a  prolonged  period,  result  in  the  chronic 
form.  Especially  is  this  the  case  with  over-use  of  the 
voice,  or  excessive  tobacco  smoking.  Nasal  obstruc- 
tion, e.g.,  from  enlarg'ed  tonsils  and  adenoids,  is 
another  cause  of  the  condition.  Similar  symptoms  are 
present  as  in  the  acute  variety.  The  hoarseness  is  a 
more  prominent  symptom  in  chronic  than  acute  cases. 

Treatment. — Any  discoverable  cause  must  be  re- 
moved. All  sources  of  irritation  must  be  discontinued 
at  least  temporarily,  such  as  smoking,  &c.  Absolute 
rest  of  the  voice  must  be  enjoined.  This  rest  may 
have  to  be  prolonged  for  a  considerable  time.  Inhala- 
tions of  tinct.  benzoinse  co.  5i  ad.  Oi,  or  of  ammon. 
chloride  (see  p.  180)  may  be  useful.  Astringents  may 
be  applied  to  the  larynx,  after  spraying  with  cocaine ; 
zinc  chloride  gr.  x  ad.  ^i,  or  silver  nitrate  gr.  xx  ad.  ^i 
are  most  frequently  employed  for  this  purpose.  The 
strength  of  the  solutions  may  be  gTadually  increased. 

Singer's  Nodes  are  a  form  of  chronic  laryngitis 
characterized  by  the  presence  of  little  hard  nodules  on 
the  vocal  cords,  which  interfere  considerably  w^ith  the 
use  of  the  voice  both  for  singing  and  speaking.  Pro- 
longed rest  may  cure  them.  If  the  patient  cannot 
undergo  this  prolonged  period  of  silence,  the  nodules 
may  be  cocainized,  and  removed  with  forceps;  this 
treatment  results  in  permanent  impairment  of  the 
voice. 


CHAPTER  XXVIII . 
CERTAIN  DISEASES  OF  NECK. 

Torticollis,  or  Wryneck,  is  a  condition  in  which 
shortening  or  over-action  of  one  sternomastoid  muscle 
occurs;  the  corresponding  trapezius  muscle  and  the 
deep  fascia  are  sometimes  involved  as  well.  The  con- 
dition may  result  from  some  cause  in  the  muscle  itself 
or  its  nerve  supply;  or  the  over-action  of  one  muscle 
may  depend  on  weakness  or  paralysis  of  its  opponent. 

The  head  is  drawn  towards  the  shoulder  on  the 
affected  side,  while  the  face  is  turned  in  the  direction 
of  the  sound  side.  The  following  varieties  of  Torti- 
collis are  described:  — 

Congenital  Torticollis  results  from  injury  either  in 
utero  or  during  delivery.  Shortening  of  the  affected 
sternomastoid  occurs,  some  of  the  muscle  fibres  being 
replaced  by  fibrous  tissue. 

Treatfneiit. — ^Massage  and  manipulation  are  usually 
given  a  trial  first,  but  in  most  cases  without  success. 
The  affected  muscle  must  then  be  divided  by  operation, 
and  the  head  fixed  in  correct  position  by  some  appara- 
tus in  order  to  avoid  subsequent  contraction. 

Acquired  Torticollis  may  result  from  affection  in  the 
muscle  itself  or  its  nerve  supply,  or  from  hysteria. 

The  chief  causes  in  the  muscle  itself  are :  — 

(i)  Exposure  to  cold,  &c.,  resulting  in  temporary 
torticollis  or  stiff-neck.  This  should  be  treated  by  the 
administration  of  aspirin  or  sodium  salicylate  (gr.  xv) ; 
a  useful  local  application  is  Antiphlogistine. 

(2)  Cicatricial  contraction  in  the  muscle  following 
some  chronic  inflammation,  e.g.,  gumma. 

The  treatment  is  the  same  as  that  recommended  for 
the  congenital  variety.  If  the  cause  of  the  contraction 
is  a  gumma,  antisyphilitic  remedies  should  be  given. 

Nervous  causes  may  be  peripheral  or  central.  Irrita- 
tion of  the  spinal  accessory  nerve  from  disease  in  its 
neighbourhood,  such  as  caries  of  the  spine  or  enlarged 


CERTAIN    DISEASES    OF    NECK  209 

cervical  glands,  may  result  in  torticollis,  either  tonic 
or  clonic  in  type. 

Central  lesions  such  as  a  neoplasm  or  cerebral 
haemorrhage  may  cause  irritation,  and  result  in  a  clonic 
torticollis. 

Treatment  must  be  directed  towards  the  removal  of 
the  cause. 

Paralytic  Torticollis  is  the  variety  which  results  from 
weakness  or  paralysis  of  one  muscle,  with  consequent 
overaction  of  its  opponent.  The  treatment  will 
depend  upon  the  nature  and  cause  of  the  muscular 
paralysis;  this  subject  is  medical  rather  than  surgical, 
and  further  description  is  therefore_omitted. 

Tuberculosis  of  Cervical  Yertebrse  (Spinal  Caries. 
Pott's  Disease\. — The  etiology  and  pathology  of  this 
condition  do  not  differ  in  essentials  from  the  descrip- 
tions previously  given  in  discussing  the  disease  in 
general  (Chapter  XII)  and  the  manifestations  of  the 
malady  in  bone  (p.  134). 

The  disease  usually  begins  in  the  vertebral  body, 
just  at  its  junction  with  the  epiphysis ;  but  any  part  of 
the  vertebra  may  be  the  starting  point.  The  occipito- 
atlantal  or  atlanto-axial  joints  are  fairly  frequent  posi- 
tions for  the  disease  to  start. 

From  its  point  of  commencement,  the  disease 
spreads  upwards  and  downwards  to  involve  neighbour- 
ing vertebrae.  Owing  to  the  destruction  of  bone  due 
to  the  malady,  spinal  curvature,  usually  antero- 
posterior, results. 

Clinical  Signs : — 

(a)  Pain  may  be  of  two  kinds  :  — 

(i)  A  local  aching  pain,  often  brought  out  by  pres- 
sure on  the  top  of  the  head. 

(2)  Referred  pain  due  to  involvement  of  the  roots  of 
cervical  nerves,  and  referred  to  the  cutaneous  area 
supplied  by  the  affected  nerves. 

(b)  Rigidity  of  the  spine  is  an  earlv  and  valuable  sign. 
In  the  early  stages,  it  is  produced  by  muscular  action, 
the  muscles  because  of  the  pain  involved,  instinctively 
endeavouring  to  limit  movement  in  the  part. 

At  a  much  later  stage,  if  the  disease  has  progressed 
favourably,  and  recovery  is  in  sight,  ankylosis  may 
occur,  and  result  in  rigidity. 

(c)  Curvature  of  the  spine  is  not  as  a  rule  a  marked 
14 


210  SURGERY    FOR   DEXTAL    STUDENTS 

feature,  when  the  disease  affects  the  cervical  region. 
Shght  deformity,  however,  may  he  detected,  with  com- 
pensatory curvatures  in  the  dorsal  and  lumbar  region. 

Retropharyngeal  abscess  is  a  fairly  frequent  compli- 
cation of  cervical  caries.  Such  an  abscess  may  dis- 
charge into  the  pharynx,  point  in  the  neck,  or  track 
deeply  for  a  considerable  distance  before  reaching  the 
surface.  In  these  latter  cases,  the  necessary  evacua- 
tion of  the  pus  is  a  matter  of  great  difficulty.  For 
information  regarding  the  complications  which  may 
ensue  from  involvement  of  the  spinal  cord,  a  text-book 
on  medicine  should  be  consulted. 

The  diagnosis  of  cervical  caries  is,  as  a  rule,  fairly 
simple,  when  pain,  rigidity  and  deformity  are  present. 
In  very  early  stages,  when  there  is  no  deformity,  the 
rigidity  is  the  most  valuable  sign.  A  skiagram  is  often 
of  great  assistance. 

Treatment. — General  treatment  in  accordance  with 
the  principles  already  laid  down  (Chapter  XII)  should 
be  carried  out. 

Absolute  immobility  of  the  diseased  portion  of  the 
spine  must  be  insured  by  suitable  apparatus.  The  spine 
will  have  to  be  kept  immobile  for  six  menths  at  the 
least,  and  in  all  probability  for  a  good  deal  longer. 

Abscesses  should  be  dealt  with  by  operation.  They 
are  usually  very  slow  in  healing. 

Diseases  and  tumours  of  the  thyroid  (Broiiehocele) 
are  treated  in  Chapter  XI. 


CHAPTER  XXIX. 
DISEASES  OF  THE  EYE. 

Conjunctivitis. 

Many  varieties  of  inflammation  of  the  conjunctiva 
are  met  with,  of  which  only  a  few  of  the  more  impor- 
tant call  for  mention  here. 

Simple  Hypersemia  of  the  conjunctiva  may  occur  as 
a  transitory  condition  resulting  from  the  presence  of  a 
foreign  body  in  the  conjunctival  sac.  There  is  some 
congestion  of  the  conjunctiva,  and  the  secretion  of 
tears  is  increased.  On  the  removal  of  the  foreign  body 
the  condition  rapidly  clears  up. 

A  more  chronic  form  of  hyperaemia  results  from 
chronic  irritation,  such  as  continued  exposure  to  a 
strong"  light,  or  to  a  dusty  atmosphere;  from  uncor- 
rected errors  of  refraction;  or  from  certain  general 
conditions,  of  which  gout  is  the  most  important.  Both 
eyes  are  usually  affected.  A  unilateral  simple  con- 
junctivitis is  usually  the  result  either  of  a  foreign  body 
in  the  eye,  or  of  some  blockage  of  the  lachrymal  duct. 

The  patient  complains  of  tiredness  of  the  eyes  with 
slight  photophobia  (literally,  dread  of  the  light),  while 
the  lachrymal  secretion  is  increased.  These  symptoms 
are  specially  noticed  after  prolonged  use.  In  cases 
due  to  errors  of  refraction,  frontal  headache  is  often  a 
prominent  feature,  while  in  gouty  cases,  there  may  be 
cedema  of  the  conjunctiva  (chemosis). 

Treatment. — The  cause  must  first  be  dealt  with.  Any 
possible  source  of  irritation  must  be  removed;  the 
lachrymal  duct  must  be  rendered  patent  by  the  passage 
of  a  probe,  if  it  be  blocked;  and  any  errors  of  refraction 
dealt  with  by  suitable  glasses.  The  conjunctival  sac 
may  be  washed  out  with  warm  boracic  acid  lotion 
gr.  V  ad.  3i. 

Mucopurulent  Conjunctivitis  is  due  to  bacterial  infec- 
tion. In  many  cases,  the  organism  responsible  is  a 
slender   Gram-negative    rod   known    as     Koch-Weeks 


212  SURGERY    FOR   DENTAL    STUDENTS 

bacillus.  In  other  cases  the  Pneumo coccus,  StapJiylo- 
coccus  aureus,  &c.,  may  be  found.  The  condition  is 
contagious,  and  consequently  frequently  transmitted. 

The  patient  complains  of  a  feeling  of  heat  and  gritti- 
ness  in  the  eye,  with  some  photophobia.  The  dis- 
charge is  at  first  watery  but  soon  becomes  mucopuru- 
lent. The  palpebral  conjunctiva  is  red  and  congested, 
the  bulbar  conjunctiva  being  less  affected.  Both  eyes 
are  generally  involved.  Sometimes  small  ulcers  occur 
on  the  conjunctiva,  accompanied  by  blepharospasm 
(spasm  of  the  lids).  If  a  corneal  abrasion  is  present, 
serious  complications  such  as  iritis  (q.v.)  may  super- 
vene. 

Treatment. — The  eyes  must  be  frequently  washed  out 
with  lot.  hydrarg.  perchlor.  i  in  5,000  diluted  with  an 
equal  quantity  of  hot  water,  which  makes  the  lotion 
warm  and  reduces  its  strength  to  i  in  10,000. 

Zinc  sulphate  gr.  ii  ad.  ji  or  zinc  chloride  gr.  i  ad.  ^i 
may  be  substituted  for  the  perchloride  lotion. 

This  lavage  must  be  carried  out  with  the  utmost  care, 
in  order  that  the  cornea  be  not  injured. 

Do  not  bandage  the  eyes.  This  is  extremely  impor- 
tant, as  fresh  air  is  of  great  value  in  the  treatment. 
The  patient  must  be  out  of  doors  as  much  as  possible. 
If  photophobia  is  troublesome,  dark  glasses  may  be 
worn,  but  on  no  account  must  the  eyes  be  bandaged. 

If  there  is  any  sign  of  iritis,  or  if  a  corneal  ulcer  be 
present,  a  small  quantity  of  atropine  (i  drop  of  a  ^ 
per  cent,  solution)  should  be  instilled  daily. 

When  the  disease  has  almost  disappeared,  the  inside 
of  the  lids  may  be  painted  with  silver  nitrate  gr.  x 
ad.  ^i;  one  application  should  be  sufficient. 

Purulent  Conjunctivitis. — In  the  great  majority  of 
cases,  the  Gonococcus  is  the  organism  responsible  for 
this  condition.  More  rarely,  staphylococcal,  strepto- 
coccal, or  pneumococcal  purulent  conjunctivitis  occurs. 
The  gonorrhoeal  variety  affects  newly-born  children,  or 
adults. 

When  it  affects  newly-born  children,  the  disease  is 
often  called  Ophthalmia  neonatorum.  Infection  may 
'Occur  during  delivery,  while  the  child's  head  is  passinof 
-from  the  uterus  to  the  vulva,  or  after  delivery  from 
want  of  cleanliness.  The  disease  usually  manifests 
-jtself  about  three  days  after  birth.     The  lids  are  red. 


DISEASES    OF    THE   EYE  213 

hot,  and  oedematous ;  chemosis  is  usually  present.  The 
pre-auricular  gland  is  commonly  enlarged;  in  adults 
there  is  considerable  pain.  The  discharge  is  serous  at 
first;  in  three  or  four  days  it  becomes  definitely  puru- 
lent. The  purulent  discharge  lasts  as  a  rule  from  five 
to  six  weeks. 

An  ulcer  of  the  cornea  may  complicate  gonorrhoea! 
conjunctivitis;  this  grave  complication  may  follow  an 
injury  to  the  cornea  either  from  the  finger  nail  or  the 
nozzle  of  a  syringe  used  for  lavage;  or  the  interference 
with  the  blood-supply  resulting  from  the  chemosis  may 
be  responsible  for  the  ulceration.  Corneal  ulceration 
and  its  possible  sequelae  are  briefly  discussed  on  p.  217. 

Treatment. — In  children  prophylaxis  is  of  the  first 
importance.  The  moment  a  child  is  born,  or  even  in 
the  short  interval  which  usually  occurs  between  the 
birth  of  the  head  and  the  remainder  of  the  body,  the 
child's  eyes  should  be  gently  but  carefully  wiped  out 
with  cotton  wool.  Then,  after  delivery,  a  drop  of  silver 
nitrate  solution  gr.  x  ad.  ji  should  be  instilled  into  each 
eye.  The  mother  and  her  attendants  must  be  impressed 
with  the  importance  of  cleanliness  in  respect  of  hand- 
kerchiefs or  towels  used  to  wipe  the  child's  eyes  sub- 
sequently. 

When  the  disease  first  makes  its  appearance,  it  is 
unilateral  as  a  rule,  but  very  prone  to  spread  to  the 
other  eye  from  direct  infection.  The  first  point  in  the 
treatment,  therefore,  is  to  protect  the  sound  eye  as 
far  as  possible.  Special  protective  shields  called 
Butler's  shields  are  used  for  this  purpose. 

The  diseased  eye  must  be  frequently  irrigated  with 
I  in  5,000  perchloride  lotion.  Syringes  should  not  be 
used,  for  fear  of  some  damage  to  the  cornea  resulting. 
Silver  nitrate  gr.  xv  ad.  ^i  iriav  be  painted  on  in  the 
early  stages,  if  no  perforation  has  occurred.  Atropin 
is  not  required  for  the  conjunctivitis  itself,  but  if 
corneal  ulceration  occurs,  the  pupil  should  be  kept  just 
dilated  with  atropin,  to  ward  off  iritis  if  possible. 

In  adults  the  urethral  condition  must  be  treated  at 
the  same  time  {see  p.  88). 

^lany  other  types  of  conjunctivitis  occur,  of  which 
a  bare  mention  will   suffice. 

Membranous  ConjunctiYitis  may  be  diphtheritic,  but 
is  not  invariablv  so.     It  should  be  treated  as  a  purulent 


214  SURGERY    FOR   DENTAL    STUDENTS 

conjunctivitis.  In  cases  due  to  the  Klebs-Loefflcr 
ha ci II MS,  diphtheria  antitoxin  should  be  employed.  It 
may  be  used  locally  as  drops,  in  addition  to  the  subcu- 
taneous injection. 

Phlyctenular  Conjunctivitis.  —One  or  more  little 
yellowish  nodules  make  their  appearance  on  the  bulbar 
conjunctiva,  just  outside  the  limbus.  These  are  called 
phlyctens.  Several  vessels  are  seen  running  up  to  the 
phlycten.  A  mucopurulent  conjunctivitis  is  usually 
present  also.  Ulceration  at  the  top  of  the  phlycten 
follow^ed  by  necrosis  may  occur,  which,  if  it  spreads 
over  the  cornea,  results  in  a  permanent  opacity. 

Phlyctens  occur  chiefly  in  children  of  the  tubercular 
or  strumous  type.  Adenoids,  enlarged  glands,  &c., 
are  often  present. 

Treatment.— l^dcYdig^    with    perchloride  lotion,    com- 
bined with  the  use  of  atropine,  sums  up  the  treatment. 
The  eye  should  not  be  tied  up,  and  the  child  should  get 
out  in  the  fresh  air  as  much  as  possible. 
Granular  Conjunctivitis  occurs  in  two  forms  :  — 
(i)  Follicular  conjunctivitis. 
(2)  Trachoma. 

Follicular  Conjunctivitis. — Small  granulations,  about 
the  size  of  a  pin's  head,  make  their  appearance  inside 
the  lower  lid.  The  granulations  are  pale  and  trans- 
lucent, and  are  arranged  in  regular  rows.  They  never 
ulcerate,  and  do  not  involve  the  cornea.  They  occur 
in  strumous  children,  and  are  often  of  the  nature  of 
adenoid  growths.  The  disease  is  not  of  any  great 
importance  in  itself,  but  requires  to  be  distinguished 
from  trachoma,  w^hich  is  a  very  grave  condition. 

Trachoma  is  an  extremely  contagious  disease,  occur- 
ring in  the  children  of  the  poor,  and  closely  associated 
with  the  dirty  conditions  of  life  which  are  almost 
inseparable  from  overcrowding.  No  specific  organism 
has  as  yet  been  isolated.  The  disease  commences  as  a 
typical'  mucopurulent  conjunctivitis  (q.v.).  Later, 
slight  ptosis  (drooping  of  the  upper  lid)  occurs,  and  on 
•examination,  granulations  will  be  found  on  the  palpe- 
bral conjunctiva  of  both  lids,  the  upper  fornices  being 
chiefly  affected.  The  bulbar  conjunctiva  is  rarely 
involved. 

The  upper  half  of  the  cornea  is  hazy,  and  superficial 
vessels  are  nresent  in  it.     This  condition  of  the  cornea 


DISEASES    OF    THE    EYE  21 5 

is  known  as  Trachouiatous  pajiuiis.  The  pannns  may 
completely  disappear  without  leaving  a  scar,  but  in 
some  cases,  permanent  opacity  results. 

Corneal  ulceration  with  its  sequelae  frequently  super- 
venes. 

Treatment. — Prophylactic  treatment  by  careful  and 
constant  inspection  of  schools,  and  immediate  isolation 
of  every  individual  case  discovered,  is  of  great  impor- 
tance. When  the  disease  has  obtained  a  footing",  the 
patient  must  be  isolated.  The  malady  is  very  chronic, 
and  treatment  may  be  required  for  a  year  or  more. 

In  the  earl}^  stages  constant  washing  out  must  be 
performed,  and  the  lids  painted  daily  with  silver  nitrate 
gr.  X  ad.  Ji. 

Later  on,  cauterization  of  the  follicles  with  solid 
copper  sulphate  is  required.  This  must  be  carried  out 
thoroughly  every  day,  special  attention  being  paid  to 
the  fornices.  It  is  extremely  painful  to  the  patient. 
\Mien  the  granulations  are  very  large  they  may  be 
expressed  bv  means  of  special  forceps  (Grady's 
forceps). 

Iritis. 

Inflammation  of  the  iris  (iritis)  is  always  associated 
with  more  or  less  inflammation  of  the  ciliary  body 
(cycliiis).  The  condition  should  therefore  strictly  be 
called  iridocyclitis;  but  it  is  usually  spoken  of  simply 
as  iritis. 

Iritis  may  result  from  corneal  inflammation  follow- 
ing conjunctivitis;  from  injury;  or  from  certain  general 
conditions,  notablv  gout,  rheumatism,  and  perhaps 
syphilis  or  tuberculosis.  In  cases  of  severe  injury  to 
one  eye,  synipathctic  iridocyclitis  may  supervene  in  the 
second  eye.  This  is  a  very  serious  condition,  almost 
always  resulting  in  loss  of  the  eye. 

The  chief  symptoms  and  signs  of  iritis  are  as 
follows  :  — 

(i)  Pain  which  comes  on  in  exacerbations,  and  is 
worse  at  night. 

(2)  Photophobia. 

(3)  A  sense  of  ''  wateriness "  but  no  actual  dis- 
charge. 

(4)  Engorgement  of  radiating  vessels  around  the 
cornea. 


2l6  SURGERY    FOR   DENTAL    STUDENTS 

(5)  Contraction  and  irregularity  of  the  pupil. 

(6)  Deepening  of  the  anterior  chamber. 
Treatment. — Rest    and    atropin    are    the    two    chief 

points  in  the  treatment.  Both  eyes  should  be  com- 
pletely rested,  and  protected  with  dark  glasses.  When 
possible,  the  patient  should  be  kept  in  bed  in  a  darkened 
room. 

Atropin  should  be  instilled,  one  drop  of  a  i  per  cent, 
solution  being-  used  six  times  a  day.  Bathing  the  eye 
with  hot  boracic  lotion  may  give  relief  to  the  pain; 
when  pain  is  a  very  severe  symptom,  a  leech  may  be 
applied  to  the  temple.  In  acute  cases  immediate  treat- 
ment on  these  lines  may  cure  the  condition  in  from 
two  to  four  weeks.  In  severe  cases,  or  when  treatment 
has  not  been  immediate,  the  inflammatory  exudates 
may  become  organized  into  fibrous  tissue.  The  pupil 
may  thus  be  fixed  to  the  lens. 

In  more  chronic  cases,  where  the  cyclitis  is  marked, 
misty  vision  and  floating  opacities  in  the  vitreous  are 
frequent  features.  Keratitis  punctata  is  the  name 
given  to  a  triangular  patch  of  dots,  on  the  back  of 
the  cornea  at  its  lo\ver  part.  This  condition  is  dia- 
gnostic of  cyclitis,  the  dots  being  the  remains  of 
exudates. 

Glaucoma  is  a  condition  in  which  the  intraocular 
tension  is  raised.  This  may  be  due  either  to  an  in- 
creased formation  of  fluid  or  to  a  blocking  of  the 
exit  for  the  fluid.  It  is  important  to  diagnose  be- 
tween this  condition  and  iritis,  as  the  treatment  of 
the  two  is  entirely  different.  In  iritis,  the  pupil  is 
small  and  irregular,  and  the  correct  treatment  is  to 
take  measures  to  dilate  it  {i.e.,  with  atropine).  In 
glaucoma,  the  pupil  is  large  and  regular.  This  may 
serve  to  remind  the  student  that  measures  which  will 
result  in  dilatation  of  pupil  are  absolutely  contra- 
indicated,  as  the  consequence  of  such  treatment  would 
be  a  further  increase  in  the  tension.  Atropin,  there- 
fore, is  required  in  iritis,  and  absolutely  dangerous  in 
glaucoma.  It  will  thus  be  seen  that  a  correct  dia- 
gnosis is  essential.  A  further  difficulty  arises  from  the 
fact  that  the  exudates  poured  out  in  iridocyclitis  may 
interfere  with  the  exit  of  fluid  and  so  actually  induce 
glaucoma.  When  the  two  conditions  are  present  at 
the  same  time,  the  greatest  experience  is  required  to 


DISEASES    OF    THE   EYE  21/ 

decide  upon  the  appropriate  treatment;  and  the  student 
who  desires  further  information  upon  this  point  should 
consult  a  text-book  specially  devoted  to  ophthalmology. 
The  following  table  may  serve  to  impress  upon  the 
reader  the  chief  points  of  difference  between  the  two 
conditions  :  — 

Iritis.  Glaucoma. 

Pupil  small.  Pupil  large. 

J,     irregular.  ,.     regular  and  oval. 

Intraocular  tension  normal  (it  may     Intraocular  tension  raised. 

be     slightly     raised    in  chronic 

cases). 
Anterior  chamber  deep.  Anterior  chamber  shallow. 

Keratitis. 

The  chief  importance  of  inflammation  of  the  cornea 
lies  in  subsequent  interference  with  vision  resulting 
from  the  permanent  opacities  which  almost  invariably 
follow. 

Ulcerative  Keratitis  most  commonly  results  from  in- 
fection after  some  slight  injury,  such  as  a  scratch  from 
a  particle  of  dust.  Trachoma  and  other  forms  of  con- 
junctivitis may  also  result  in  corneal  ulceration.  Very 
superficial  ulcers,  which  do  not  destroy  Bowman's 
membrane,  heal  without  leaving  any  scar.  When 
Bowman's  membrane  is  involved,  which  is  almost 
always  the  case,  a  permanent  scar  always  remains. 
These  opacities  are  given  different  names,  according 
to  their  density,  which  depends  upon  the  depth  to 
which  the  ulcer  penetrates.  A  very  thin  scar  is  called 
a  nebula;  a  macula  is  a  somewhat  denser  opacity;  while 
a  thick,  white,  opaque  patch  is  known  as  a  leukoma. 
The  interference  with  vision  due  to  an  opacity  depends 
upon  the  area  and  position  of  that  opacity  as  well  as 
its  thickness. 

Localized  inflammation  and  destruction  of  the  super- 
ficial layers  of  the  cornea  occur,  forming"  a  somewhat 
saucer-shaped  ulcer.  Vascularization  of  the  cornea 
follows  as  the  ulcer  heals.  Even  if  there  is  not  com- 
plete perforation,  some  iritis  is  usually  present.  The 
symptoms  of  corneal  ulceration  are  pain,  lachrymation, 
blepharospasm  and  photophobia. 

The  treatment  of  a  simple  ulcer  includes  irrigation 
with  warm  boracic  lotion,  and  the  use  of  one  drop  of 


2l8  SURGERY    FOR   DENTAL    STUDENTS 

J  per  cent,  atropin  three  times  a  day  as  a  precaution 
against  iritis.     The   eye  should  he   bandaged. 

The   chief  compHcalions  which   occur   are :  — 

(1)    Perforation When     perforation     occurs,     the 

aqueous  humour  escapes,  the  iris  and  anterior  surface 
of  the  lens  therefore  being  in  contact  with  the  posterior 
surface  of  the  cornea.  Part  of  the  iris  may  pass 
through  the  perforation;  this  is  known  as  prolapse  of 
the  iris.  The  lens  may  adhere  to  the  cornea  and  this 
will  result  in  a  permanent  opacity  on  the  anterior  sur- 
face of  the  lens,  which  is  known  as  an  anterior  capsular 
cataract.  Virulent  organisms  may  gain  access  to  the 
interior  of  the  eye  through  the  perforation,  resulting 
in  infective  iridocyclitis;  or  even  an  infective  inflamma- 
tion of  the  whole  eye,  which  is  called  pauophthalmitis. 

(2)  Hypopyon  is  a  collecton  of  pus  at  the  bottom  of 
the  anterior  chamber.  This  may  occur  without  per- 
foration, being  then  composed  simply  of  exudates  from 
the  iritis  which  is  usually  present :  the  hypopyon  in 
such  a  case  is   sterile. 

If  perforation  occurs,  the  hypopyon  necessarily  be- 
comes infected. 

Treatment. — A  deep  ulcer,  which  has  not  perforated, 
should  first  be  stained  with  fluorescin  (which  stains 
the  ulcer  yellow,  and  does  not  affect  the  remainder 
of  the  cornea);  the  base  of  the  ulcer  should  then  be 
cauterized  with  pure  carbolic  acid,  cocaine  having  been 
previously  instilled.  The  eye  should  then  be  tied  up, 
and  the  patient  kept  quiet  in  bed  in  order,  if  possible, 
to  avoid  perforation. 

When  the  ulcer  is  so  deep  that  perforation  seems 
inevitable,  it  may  be  wise  to  perform  paracentesis ; 
that  is,  to  incise  the  cornea  with  a  special  needle,  so 
that  the  aqueous  may  be  allowed  to  escape  less  sud- 
denly than  would  have  been  the  case  had  the  ulcer 
been  left  to  perforate  in  the  ordinary  way. 

When  perforation  has  occurred,  the  patient  must  be 
kept  absolutely  still,  all  coughing  and  sneezing  beins: 
avoided  where  possible.  Atropin  should  be  instilled, 
as  for  iritis,  and  the  eye  firmly  bandaged.  If  prolapse 
of  the  iris  occurs,  the  prolapsed  portion  should  be 
excised. 

If  such  a  condition  as  panophthalmitis  arises,  ex- 
cision of  the  eyeball  will  usually  be  required. 


DISEASES    OF   THE   EYE  219 

Interstitial  Keratitis  is  an  important  manifestation 
of  congenital  syphilis.  It  occurs  between  the  ages  of 
5  and  15,  and  is  really  a  keratitis  which  is  secondary 
to  iridocyclitis.  Both  eyes  are  affected,  but  usually 
one  later  than  the  other. 

At  first,  there  are  symptoms  of  irritation  in  the  eye, 
with  slight  ciliary  congestion.  Then  hazy  patches 
appear  which  are  situated  deep  in  the  cornea.  At  a 
later  period,  the  whole  cornea  is  ''  steamy,"  and 
vascularization  of  the  cornea  occurs.  The  newly- 
formed  leashes  of  vessels,  shovv^ing  through  the  steamy 
cornea,  give  rise  to  typical  pinkish  patches,  known  as 
sahnon  patches.  Vision  is  interfered  wdth  consider- 
ably, while  blepharospasm  and  photophobia  are  marked 
features. 

Treatment. — Antisyphilitic  remedies  appear  to  have 
no  effect.  Atropin  should  be  given  for  the  iritis;  dark 
glasses  should  be  used. 

Fine  lines  remain  permanently  where  the  corneal 
vessels  existed;  this  is  important  evidence  of  congeni- 
tal syphilis. 

Ptosis,  or  drooping  of  the  upper  lid,  may  be  con- 
genital or  acquired. 

Congenital  Ptosis  is  almost  always  bilateral,  and 
most  often  due  to  imperfect  development  of  the  levator 
palpebras  superioris;  in  rare  cases  it  may  result  from 
cerebral  mal-development. 

Acquired  Ptosis  is  usually  unilateral,  and  may  result 
from  a  lesion  in  the  central  nervous  system  (in  which 
case  it  is  associated  with  paralysis  of  other  muscles 
supplied  by  the  third  cranial  nerve),  or  from  injury. 
In  rare  cases,  it  is  due  to  increased  weight  of  the  lid. 

Treatment  necessarily  depends  on  the  cause.  Opera- 
tive measures  have  been  devised,  but  the  results  have 
not  been  encouraging. 

Strabismus,  or  Squint- 
Strabismus  may  be  of  three  kinds:  — 
(i)  Paralytic   Strabismus,    due    to    paralysis    of   one 
or  more  eye  muscles. 

(2)  Kinetic  Strabismus ,  due  to  overaction  of  one 
or  more   eye  muscles. 

(3)  Concomitant  Strabismus y  the  cause  of  which  is 
unknown. 


220  SURGERY    FOR   DENTAL    STUDENTS 

(1)  Paralytic  Strabismus. — There  exists  limitation  of 
movement  in  the  direction  in  which  the  affected  muscle 
should  act.  The  chief  symptom  experienced  by  the 
patient  is  diplopia,  most  marked  in  the  slight  cases. 

Treatment  will  depend  upon  the  nature  of  the  lesion 
to  which  the  paralysis  is  due.  Syphilitic  cases  may 
improve  on  anti-syphilitic  treatment. 

Operative  measures,  such  as  tenotomy  of  the  oppos- 
ing muscle,  may  be  of  value. 

(2)  Kinetic  Strabismus  is  mostly  the  result  of  irrita- 
tion of  the  cerebral  centres  bv  tumours,  meningitis, 
&c. 

(3)  Concomitant  Strabismus  is  thus  described  by 
Parsons :  "  The  visual  axes,  though  abnormally 
directed,  retain  their  abnormal  relationship  to  each 
other  in  all  movements  of  the  eyes." 

The  condition  usually  begins  in  childhood,  and  is 
frequently  associated  with  errors  of  refraction.  The 
treatment,  therefore,  involves  the  correction  of  these 
errors   of  refraction. 


CHAPTER  XXX. 
DISEASES  OF  THE  SKIN. 

The  subject  of  skin  disease  will  be  treated  in  strict 
accordance  with  the  requirements  of  the  examinations 
for  the  various  dental  diplomas  and  degrees,  and  the 
reader  will  understand  that  these  limitations  are 
obligatory  from  considerations   of  space. 

A  Wart  is  a  papilloma  of  the  skin.  It  most  fre- 
quently attracts  notice  as  a  hard  growth,  about  the 
size  of  a  pea.  It  is  most  common  in  young  people, 
the  hands  being  usually  affected.  The  surface  of  the 
growth  may  be  smooth  or  papillated.  In  moist  re- 
gions, the  growths  may  become  much  softer  in 
character.  They  are  generally  multiple,  and  usually 
follow  some  chronic  irritation. 

Warts  are  best  treated  by  cauterization  with  acetic 
or  nitric  acid.  Carbon  dioxide  snow  has  been  used 
with  success. 

A  Corn   may  be  hard  or  soft. 

A  hard  corn  is  a  horny  growth  of  the  epidermis, 
which  occurs  in  positions  subjected  to  undue  irritation, 
especially  the  toes,  and  is  usually  single.  It  is  often 
a  source  of  considerable  pain. 

A  hard  corn  may  be  treated  by  paring  with  a  razor 
after  immersion  in  hot  water.  The  source  of  irritation 
should  be  removed,  and  the  situation  of  the  lesion 
protected  from  pressure. 

The  following  prescription,  painted  on  the  corn  three 
times  a  day  for  a  week,  may  be  very  useful:  — 

B  Acid,   salicyl. 

Extr.   cannabis  indicse 
Spir.  vini    rect. 

^ther  

Collodii 
Fiat  pigmentum. 

In  the  obstinate  cases  it  may  be  necessary  to  ampu- 
tate the  affected  toe. 

Soft  corns  occur  most  commonly  between  the  toes. 


gr. 

,  XV. 

gr. 

,  viii. 

m. 

15- 

m. 

40. 

m. 

75. 

222  SURGERY    FOR   DENTAL    STUDENTS 

They  are  smaller  than  hard  corns,  and  usually  multiple. 
They  should  be  treated  with  salicylic  acid  to  remove 
the  cuticle:  and  vaseline  or  cottonwool  soaked  in 
boracic  acid  lotion  should  be  placed  between  the  toes 
to  avoid  subsequent  irritation. 

A  Keloid  is  a  growth  composed  of  fibrous  or  scar 
tissue.  In  the  great  majority  of  cases  it  arises  in  a 
scar,  but  is  said  also  to  occur  spontaneously.  The 
cause  has  not  been  definitely  determined,  but  it  is  sup- 
posed to  be  infective  in  origin.  It  grows  slowly,  but 
may  attain  veiy  large  dimensions.  If  removed,  it 
almost  invariably  recurs  in  the  scar.  Operative  treat- 
ment is  therefore  rarely  successful.  Both  X-rays  and 
radium  have  been  employed  with  benefit  in  some  cases. 

A  Rodent  Ulcer  is  a  carcinomatous  condition  of  the 
skin,  which  differs  from  an  epithelioma  both  in  its 
origin  and  clinical  course.  Opinions  are  divided  as  to 
whether  it  originates  from  a  sebaceous  gland  or  a  hair 
follicle,  but  it  seems  clear  that  it  is  not  a  down  growth 
from  the  epithelium  {cf.  Epithelioma). 

The  growth  is  rare  except  on  the  face,  the  side  of 
the  nose  near  the  inner  canthus  being  the  most  fre- 
quent situation. 

It  commences  as  a  small,  hard,  flat  nodule,  in  which 
after  a  varying  period  ulceration  takes  place.  The 
ulcer  thus  formed  is  flat,  irregular,  and  of  an  unhealthy 
appearance;  the  edges  are  usually  slightly  raised  and 
indurated. 

The  ulcer  increases  in  size  very  slowly,  often  remain- 
ing apparently  stationary  for  months  at  a  time.  It  is 
very  destructive  in  character,  even  the  bone  being 
attacked.  The  glands  are  not  involved,  and  no 
secondary  deposits  are  formed.  Cachexia  is  rare, 
except  in  the  last  stages.  Microscopically,  the  growth 
will  be  found  to  be  composed  of  columns  of  epithelial 
cells  embedded  in  fibrous  tissue.  The  individual  cells 
are  smaller  than  in  epithelioma;  prickle  cells  do  not 
occiu",  and  cell  nests  are  rarely  seen. 

The  diagnosis  is  not  usually  difficult,  when  the 
position,  appearance,  and  slow  growth  are  considered 
{vide  Lupus,  p.  223). 

Treatment. — X-rays  and  radium  have  been  em- 
ployed, and  in  the  early  stages  are  often  of  great  value. 

Operative    treatment    consists    in    free    excision;    or 


DISEASES    OF    THE    SKIN  223 

where  this  for  anatomical  reasons  is  impossible,  free 
scraping"  and  application  of  the  actual  cautery. 

Carcinoma  of  the  skin  may  occur  (either  primary  or 
secondary).  Secondary  deposits  of  sarcoma  also  occur. 
Primary  sarcoma  of  the  skin  is  rare. 

Lupus  vulgaris  is  a  chronic  affection  of  the  skin,  due 
to  the  activity  of  the  tubercle  bacillus.  It  commonly 
occurs  on  the  face,  a  frequent  situation  for  the  disease 
to  commence  being'  behind  the  ala  of  the  nose,  at  its 
junction  with  the  cheek.  It  usually  begins  during 
childhood,  but  being  a  very  chronic  malady,  is  often 
met  with  in  later  life. 

Svfuptonis. — The  lirst  sign  of  the  condition  is  usually 
the  appearance  of  one  or  more  dull-red  spots  about 
the  size  of  a  pin's  head,  which  are  most  commonly 
slightly  raised  above  the  level  of  the  skin.  They  do 
not  disappear  on  pressure,  though  they  become  con- 
siderably paler.  As  the  spots  increase  in  size,  they 
show  a  brownish  colour  and  a  peculiar  translucent 
appearance,  Avhich  has  earned  them  the  name  of  Apple 
jelly  nodules.  They  feel  rather  like  small  shot  under 
the  skin.  Slowdy  they  increase  in  size,  two  or  more 
nodules  frequently  coalescing  to  form  one  larger  patch. 
As  the  patches  increase  in  size  scales  form  on  the 
surface. 

Though  its  progress  is  very  slow,  lupus  is  very 
destructive,  all  the  soft  parts  being  liable  to  attack; 
the  bones,  however,  very  rarely  suffer.  The  disease 
does  not  progress  continuously,  but  often  appears  to 
improve  for  a  time,  only  to  advance  once  more. 

In  the  later  stages  ulceration  may  occur,  especially 
if  mucous  membranes  are  involved,  the  surface  being 
covered  with  g-reenish  crusts,  from  Avhich  thin  puru- 
lent fluid  is  discharged. 

The  diagnosis  in  a  typical  case  is  easy.  Syphilitic 
affections  progress  more  rapidly,  as  a  rule,  and  com- 
monly commence  in  adult  life.  Ulceration  occurs 
more  readily  than  in  lupus.  Epithelioina  will  not,  as  a 
rule,  be  mistaken  for  lupus;  its  hard  everted  edge,  the 
pain  caused,  and  the  tendency  to  involve  neighbouring" 
glands  are  important  points  in  the  diagnosis.  It  must 
not  be  forgotten  that  the  two  conditions  may  be  met 
with  together,  because  the  epithelioma  may  form  in 
the  lupus  scar  tissue. 


224  SURGERY    FOR   DENTAL    STUDENTS 

A  rodent  ulcer  is  very  rarely  multiple,  and  very 
rarely  is  there  more  than  a  slight  amount  of  discharge. 
It  commonly  begins  at  a  much  more  advanced  age 
than  does  lupus. 

Treatment. — Very  varied  methods  of  treatment  have 
been  suggested  for  dealing  with  this  disease.  Ordinary 
measures  must  be  taken  to  support  the  general  health, 
as  has  been  described  in  dealing  with  all  the  manifesta- 
tions of  tuberculosis. 

Extr.  thyroidei  may  be  given  internally,  commencing 
with  gr.  V  during  the  day,  the  dose  being  gradually 
increased  to  gr.  xv,  or  even  gr.  xx  in  the  twenty-four 
hours. 

Tuberculin  injections  rarely  appear  to  have  more  than 
temporary  effect. 

Excision  may  be  of  great  value,  especially  in  quite 
early  stag'es.  When  the  disease  affects  the  face,  it  may 
be  difficult  to  obtain  the  patient's  consent  to  this  opera- 
tion.    The  actual  cautery  has  also  been  employed. 

Great  improvement  may  be  obtained  from  the  use  of 
the  Fins  en  light  treatment.  Radium  and  X-rays  have 
also  been  used.  The  details  of  these  methods  are  out- 
side the  scope  of  this  handbook. 

Local  applications  are  mostly  used  simply  to  render 
the  part  aseptic.  Such  preparations  as  ung.  acidi  bor. 
are  useful.  Caustic  drugs  are  rarely  used  nowadays, 
as  they  involve  more  pain  than  the  other  methods 
described. 

Acne  Vulgaris  is  an  inflammation  of  the  sebaceous 
glands,  due  to  blocking  of  their  ducts.  It  affects 
chiefly  boys  from  about  15  to  25  years  old.  It  is 
certainly  micro-organic  in  origin,  but  opinions  are 
divided  as  to  the  particular  organism  present.  In  all 
probability  there  are  several  bacteria  which  may  pro- 
duce the  condition. 

The  individual  comedo  begins  as  a  red  papule, 
often  very  tender,  and  surrounded  by  a  zone  of  hyper- 
semic  skin.  It  soon  becomes  pustular;  it  often  has  a 
central  black  spot.  Large  acne  spots  often  leave 
scars. 

The  common  situations  for  the  disease  are  the  back 
and  shoulders,  and  less  frequently  the  chest,  face, 
neck  and  buttocks. 

There  are  many  conditions  which  predispose  to  the 


DISEASES    OF    THE    SKIN  225 

disease.  Any  mechanical  blockage  of  the  duct,  e.g., 
by  dirt,  may  bring  on  an  attack.  Also  general  dis- 
turbances, such  as  constipation,  debility,  and  men- 
strual disorders  render  a  patient  more  liable  to  the 
disease. 

Diagnosis  is  very  easy  from  the  age  of  patient,  and 
position  and  appearance  of  the  lesion.  The  possibility 
of  a  drug"  rash,  such  as  bromide,  &c.,  must  be  borne 
in  mind  in  making  a  diagnosis. 

Treatment. — General  hygiene  treatment  must  be 
employed,  and  any  of  the  predisposing  causes  men- 
tioned above  dealt  with  if  present. 

Local  treatment  by  incising  the  individual  pustules 
with  a  clean  instrument,  squeezing  out  the  pus,  and 
applying  sulphur  ointment  is  usually  sufficient. 

In  very  obstinate  cases,  vaccines,  prepared  from 
the  particular  micro-organism  present  in  the  case,  may 
be  employed,  often  with  great  benefit. 


15 


INDEX. 


Abscess,  acute,  22 

— ,  chronic,  22 

— ,  cold,  22 

— ,  diagnosis      of      sebaceous 

cyst  from,  117 
— ,  retropharyngeal,   180 
Accessory  sinuses,  diseases  of, 

1Q9-203 
Acne  vulgaris,  224 
Actinomyces,  or  Ray  Fungus, 

100 
Actinomycosis,    100 

—  (bovine),  100 
— ,  cause  of,  6 

— ,  diagnosis,    loi 

—  (human),    100 

—  of  jaws,    loi,    189 

—  of  tongue,   187 

—  simulating  chronic  appen- 

dicitis, 10 1 
— ,  treatment,  loi 
Acromegaly,  78 
— ,  changes  in  mandible,   in, 

79 
■ ,  in      temporo-maxillary 

joint  m,   79 
— ,  connection     of     abnormal 

enlargement  of  pituitary 

body  with,  78,  79 
— ,  treatment,  80 
Acu-puncture    (Macewen's)    in 

aneurism,  57 
Adenoids,  180 
Adenoma,  112 

—  of  thyroid,  yy 
- — ,  treatment,  1 12 
Adhesions  in  ankylosis  of  jaw, 

breaking  down,  160 
Adrenalin,   39 

—  in   haemorrhage   following 

extraction  of  teeth,  39 

—  solution,  plugging  nostril 

with  cotton-wool   soaked 
with,  in  cpistaxis,  198 


Aerobes,  4,  5 

— ,  facultative,   5 

Air   passages,    foreign   bodies 

in,   164 
Alcohol,       forbidden      during 

acute     attack     of     gout, 

153 
Alcoholism,   9 
Alum,   powdered,    as    styptic, 

Ammonium     chloride     in     tic 

douloureux,   64 
Amputation    in    acute    osteo- 
myelitis, 132 

—  in  gangrene,  33.  34 
Anaemia,     secondary     haemor- 
rhage in   subjects  of,  52 

Anaerobes,  4 
— ,  facultative,  5 
Anaesthetics    in    manipulation 

and  traction  of  fractures, 

121,  122 

—  (general),  sudden  death  of 

subjects  of  status  lymph- 
aticus  under,   105 
Aneurism,  56 

—  (arterio-venous),    57 
— ,  clinical  signs,  56 
— ,  diagnosis,  56 

—  (diffuse,  traumatic),  57 

—  (dissecting),  56 

—  following  arteritis,  55,  56 

—  (fusiform),  56 

■ — ■    (sacculated),  56 
— ,  treatment,  57,  58 

—  (varicose),  57 
Angeioma,    no 

— ,  cavernous,    100,    see    also 

Naevus,    venous 
Ankle-joint  dislocation,  151 
,  diagnosis    by    X-rays, 

Ankylosis  of  jaw,  false,   160 

—  of  jaw,  true,  160 
— ,  treatment,   160 


INDEX 


227 


Anodynes  in  chronic  neuritis, 

63 
Anthracsemia        (wool-sorter's 
disease),  87 

—  treatment,  87 
Anthrax,  86 

— ,  local  lesion  of,  87 

— ,  micro-organism      causing, 

86 
— ,   symptoms,  87 
— ,  treatment,  87 
Antibodies,  and  active  acquired 

immunity,  9 
Antiphlogistine      in      acute 

neuritis,  62 

—  in  herpes  zoster,  69 
Antisepsis,  definition,   11 
Antiseptics,  5 

Antitoxins  in  bacterial  infec- 
tions, 25 

Antrum  of  Hiphmore,  see 
Maxillary  sinus 

— ,  tumours  of,  202 

Appendicitis  (chronic)  simu- 
lated   by    actinomycosis, 

lOI 

.A-ppendix,  removal,  opera- 
tions for,  aseptic  and 
antiseptic  precautions 
during,  12,  13 

Apple-jelly  nodules  of  lupus 
vulgaris,  223 

Arsenic  in  chronic  lympha- 
denitis, ^■^f 

—  in    treatment    of    syphilis, 

96 
Arteries  (atheromatous),  55 
— ,  diseases  of,  55-60 
— ,  ligature  in   aneurism,    57, 

58 
— ,  wounded,         control        of 

haemorrhage     from,     41, 

42 
Arteritis   (acute  and  chronic), 
aneurism,  following,  55, 

56 

—  (acute),  infective,  55 

—  — ,  non-infective,    55 

—  (chronic),  55 

—  — ,  causes,   55 

—  (tuberculous),     56 
Arthritis  (acute),  152 

-,  diagnosis,   152,   153 

,  infective,   153 

,  treatment  of  traumatic 

cases,  153 

—  (gonorrhceal),   154 


Arthritis  (gonorrhoeal)  in  tem- 
poro-maxillary  articula- 
tion,  rare,    159 

—  (infective)      of      temporo- 

maxillary      articulation, 
159. 

—  (septic),  how  caused,   139 

—  (syphilitic),    156 

—  (tuberculous),    154 

—  — ,  diagnosis,   155 

—  — 5  treatment,  155,  156 
Asepsis  and  antisepsis,  11-17 
— ,  definition,  11 

Aspirin  in  herpes  zoster,  69 
Asthenia    in    acute    spreading 

traumatic  gangrene,  34 
Atheroma  of  arteries,   55 
Axillary  vessels,  injury  to  in 
dislocation    of    shoulder- 
joint,  147 

Bacilli,  3 

Bacillus  anthracis,  86 

—  di-phtlierise^    175,    176 

—  —  as  cause   of  membran- 

ous conjunctivitis,  214 
Bacillus    (Ducrey's)    cause    of 
soft  chancre,  90 

—  (Ducrey's),  staining  of,  go 

—  (Koch- Weeks),  211 
Bacillus     o^deniatis     vialigni, 

presence  in  acute  spread- 
ing traumatic  gangrene, 
34 
— ■    tetania  description,  83 

—  tuberculosis^  97,  98 
Bacteria,   i 

— ,  chemical  substances  de- 
structive of,  5 

— ,  classification,    2,  4 

— ,  effect  of  heat  on,  5 

of  sunlight  on,   5 

— ,  optimum  temperature  for, 
5 

— ,  parasitic,  4 

— ,  reproduction,    i 

— •  — ,  by  fission,    i 

,  by  spore-formation,  I,  2 

— ,  saprophytic,  4 

Bacterial  invasion  in  inflam- 
mation, 22,  23,  24 

Bacteriology,    i-io 

Barlo\y's  disease,  see  Scurvy 
(infantile) 

BelTs  palsy,  66 

Belladonna,  see  Glycerine  of 
belladonna. 


228 


INDEX 


Bier's  treatment  in  tuberculous 
arthritis,    156 

Blackwash  in  lavage  of  pri- 
mary   sore    of    syphilis, 

94 

Blastomycetes,  5 

Blood,  protein  in,  styptics  in- 
ducing   coagulation    of, 

39  . 

— ,  coagulation  period  in- 
creased in  haemophilia, 
104 

Blood  corpuscles,  red,  in  in- 
flammation,  19 

Blood  cysts,   118 

Blood-vessels,  dilatation  in 
inflammation,    18 

— ,  styptics  causing  local 
constriction  of  blood- 
vessels, 39 

Boils,  35,  36 

— ,  treatment,  36 

Bone, carcinoma  of,  secondary, 
138 

— ,  contusions  of,  119 

— ,  caries  of,  syphilitic,  135 

— ,  diseases  of,   130-138 

— ,  fibroma  of,  137 

- — ,  gummata      of,      multiple, 

.  ^35 
— ,  inflammatory      affections, 

.  ^30  . 

— ,  inflammation,  chronic,  133 
— ,  injuries  of,    1 19-129 
— ,  necrosis  of,  130,  133 
— ,  new,  formation  of,  130 
— ,  sarcoma  of,    137 

—  ■ — -,  central,    137 

—  — ,  diagnosis,    137 
,  by  X-rays,  137 

—  — ,  myeloid,   137,   138 

—  - — ■,  periosteal,   137 
- — ■  - — ,  secondary,   138 

,  treatment,  137,  138 

— ,  sclerosis  of,  133 

,  diffuse  syphilitic,  135 

,  causes,  133 

—  — ,  treatment,  134 

,  rarefactive     osteitis 

combined  with,  133 
— ,  syphilitic  diseases  of,  135, 

136 
— ,  tuberculosis  of,  134 
Bones,  changes  in  rickets,  102 
Brain,  compression  following 
fractures  of  skull,  124 


Brain,    concussion     following 

fractures  of  skull,   124 
Bromides  in  facial  spasm,  68 
Broncho-pneumonia     (septic), 
from      swallowing      dis- 
charge in  cancrum  oris, 

.  35 
Bruises,  37 

BuUer's    shields,    for    use    in 
ophthalmia  neonatorum, 
213 
Burns  and  scalds,  44-47 
,  complications    and    se- 
quelae, 45,  46 
,  degrees    of    injury    in, 

44,  45 

,  of  tongue,   183 

—  ■ — ,  pathological  processes, 

45 

,  prognosis,  46 

,  shock  following,  46 

■ —  — ,  treatment,  46 

—  — -  — ,  by     application     of 

dressings,  46 

—  due   to  lightning   or  elec- 

tricity, 47 

Calcium,  as  styptic,  40,  41 
— ■  —    in  teeth  extraction,  41 
— •    chloride  in  haemophilia  as 

local    styptic,    104 
,  internal        administra- 
tion, 104,  105 
Calculus,   salivary,    170 
Caldwell-Luc    operation,    de- 
scription of,   202 
Callus,    provisional    and    de- 
finitive, formation  of,  in 
union  of  fractures,    119, 
120 
Cancer,  acute,  114 

—  of  thyroid  gland,  77,  78 
Cancrum   oris,   35,    169 

,  complications,  35 

,  results    of    swallowing 

discharge,  35 
Carbuncles,  36 
— ,  treatment,  general,  36 

-,  local,  36 

Carcinoma,      columnar-celled 

or  glandular,  114 
— ,  distinction  from  sarcoma, 

1 12 
• —    (encephaloid),    114 
,  colloid       degeneration 

in,  114 


INDEX 


229 


Carcinoma,  nature  of,  112 

—  of  bone,  secondarVj  138 

—  of  jaws,   193 

—  of  mouth,    171 

—  of  parotid  gland,  205 

—  of   pharj'nx,    180 
— -    of  skin,  223 

—  of  tonsils,  179 
— ,  scirrhus,    113 
— ,  secondary,  74 

— ,  spheroidal-celled,    113 

— ,  squamous,  see  E-pithelioma 

— ,.  treatment,    114 

Caries,  syphilitic,  of  bone,  135 

Cartilage  and  bone,   tumours 

of,  simple,   136 
— •  — ,  tumours  of,  malignant, 

137 
Catarrh,   20 

—  of     frontal     sinus,     acute, 

203 
Cattle,  actinomycosis  in,  100 
Cellulitis,  22 

—  complicating    injuries    of 

scalp,    163 
— ,  gangrenous,  22 
Cementoma,    192 
Chancre     (hard)     of    primary 

syphilis,  92 

—  (soft),  89,  90 

— ■  — ,  diagnosis  from  hard 
chancre  of  syphilis,  90 

,  incubation  period,  90 

,  micro-organism  caus- 
ing, 90 

,  treatment,  91 

Charcot's  disease,  159 

— •  — ,  diagnosis,  159 

occurring  during  tabes 

dorsalis  or  syringomye- 
lia,   159 

of  tempore  -  maxillary 

joint  rare,   160 

—  — ,  treatment,  159 
Children,     acute    rheumatism 

rare  in,   132,  153 

Chloral  hydrate  and  potas- 
sium "bromide  in  tetanus, 
86 

Chloroform  in  tetanus,  86 

Chondroma,  109 

Cleft-palate,   171 

— ^j  how  produced,  171,  172 

— J  treatment,  operative,  de- 
scribed,   173,    174 


Cleft-palate,  treatment,  opera- 
tive, time  for  perform- 
ance, 172 

Clergyman's  sore  throat,  180, 
see  also  Pharyngitis, 
chronic 

Cloacae,   130 

Cobb's  nasal  splint,  125 

Cocci,  2 

— ,  classification,    2 

Cold,  application  in  inflam- 
mation, 24 

— ,  extreme,  does  not  de- 
stroy bacteria,  5 

Cold  catching,  breakdown  of 
immunity,   8 

Coley's  fluid,  administration 
in   sarcoma,    112 

Collapse,    53 

—  in  wounds  of  neck,   164 
— ■,  treatment,   53 

Colloid  degeneration  in  en- 
cephaloid  cancer,  114 

Condyloma  of  secondary 
syphilis,  93 

■  — ,  local  treatment,  95 

Conjunctiva,  hyperaemia  of, 
simple,  211 

Conjunctivitis,  micro-organ- 
ism causing,  211 

— ,  follicular,    214 

— ,  gonorrhoeal,  89 

— ,  granular,  214 

— ,  membranous,  213 

—  (mucopurulent),   211 
,  bandaging     eyes     for- 
bidden in,   212 

,  treatment,  212 

— ,  phlyctenular,  214 

— ,  purulent,   212 

Contusions,  2)1 

— ,  treatment,  38 

Corns,  221 

— ,  application    of    paints    to, 

22 1 
Counter-irritation,  24 
—    in  chronic  lymphadenitis, 

72 
— ■    in  herpes  zoster,  69 
Cradle  splint  for  fractures  of 

lower  jaw,  128,  129 
Craniotobes  in  rickets,  102 
Crepitus  in  fractures,  121 
— ■    in  teno-synovitis,  121 
Cretinism,  75 
Cyst,  dental,  192 


230 


INDEX 


Cyst,   dentigerous,    see   Odon- 

toiiie,  follicular 
Cysts,   116-118 

—  connected    with    rudimen- 

tar}^  sexual  organs, 
117 

— ,  dermoid,  of  mouth,   170 

- — ,  due  to  distension  of  pre- 
existing  spaces,    117 

— ,  due  to  presence  of  foreign 
bodies,    118 

— ,  mucous,  117 

—  of  degeneration,  118 

—  of  embryonic  origin,   116 

—  of  floor  of  mouth,  170 

—  of  new  formation,  117 
— ,  parasitic,  117 

—  (sebaceous),   117 

,  diagnosis  from  abscess 

or  lipoma,  117 

—  — ,  treatment,    117 
— ,  serous,  118 

Degeneration-cysts,  118 

Dentures  (artificial)  impacted 
in  oesophagus,  166 

5  swallowed,  how  to  ex- 
tract, 165 

Dermoids,  116,  see  also 
Sequestration  dermoids ; 
Tiihulo-der  molds 

— ,  treatment,  117 

Diabetes  mellitus,  q 

■  -,  see  also  Gangrene  (dry, 
diabetic) 

Diapedesis    in    inflammation. 

Digitalis  in  exophthalmic 
goitre,   ^j 

Diphtheria,  175 

— ,  bacjllus  causing.   175,   176 

— ,  complications,  176 

— ,  incubation  period,  176 

— ,  infection,  local  and  gen- 
eral in,  8 

— ,  nose  affected  by,  195 

— ,  symptoms,   176 

— ,  treatment,  177 

,  operative  by  trache- 
otomy,  177 

Diphtheria  antitoxin,  10 

Diplococci,  2 

Dislocations,  130-150 

— ,  causes,  exciting,  140 

,  predisposing,    140 

— ,  classification,    140 


Dislocations,  compound,    142 
— ,  congenital,    140 
— ,  diagnosis,  141 

—  -    — ,  from  fracture,  141 

—  — -,  from  sprain,  141 
— ,  general   signs,    141 

—  of   ankle-joint,    151 
—    of  hip-joint,  148-150 

—  of  knee-joint,  150 
— •    of  lower  jaw,   142 

—  of  patella,    150 

—  of  shoulder-joint,  144-147 

—  of  thumb    (first   phalanx), 

148 

—  of  wrist,   148 

— ,  pathological,  140 

— ,  treatment     by     reduction, 

141 
Dog  bites,  44 
Dressers,  surgical  cleanliness 

Dressings,  application  after 
burns  and  scalds,  46 

Ducrey's  bacillus,  cause  of 
soft  chancre,  qo 

Duodenum,  ulceration  of,  fol- 
lowing burns  and  scalds, 
46 

Ear,  middle,  disease  of,  64 

Ecchymoses,  ^iJ 

Ecthyma  of  secondary  syphi- 
lis, 93 

Eczema  around  ulcer,  treat- 
ment,  29 

Effusion,  chronic,  21 

Elbow,  pulled,  148 

Elbow-joint,  dislocations,   147 

—  — ,  treatment,  147 
Electric  current  and  gold  wire, 

introduction  in  aneurism, 

57 
Electrical       treatment      after 

operation  on  nerves,  62 

of  facial  spasm,  68 

in    neuritis,    acute    and 

chronic,  62 
Electricity,  burns  due  to,  47 
Electrolysis   in    macrocheilia, 
.  72 

—  in  macroglossia,  72 
Elephantiasis,  70 

—  Arabum,  71 
— ,  false,  71 

— ,  treatment,  71 
Emboli,  malignant,  iii 


INDEX 


231 


Embrvonic  origin,  cvsts  of, 
i'i6 

Emphysema  (surgical)  in 
acute  spreading  trau- 
matic gangrene,  34 

■ ,  in     injuries    of    scalp, 

163 

Empyema,  antral,  acute,  200 

—  --,  chronic,   201 

,  treatment,    201,    202 

,  by      extraction      of 

tooth,  201,  202 
,  by     radical      opera- 
tion.  202 

—  of   frontal   sinus,   chronic, 

l-'ndarteritis,  syphilitic,  55 
Endothelioma,   106,   114 
Epiphysitis,  congenital  syphi- 
litic,   135 
Epistaxis,   53,    197 
— ,  bleeding-point  in  nose  in, 

197 

- — ,  treatment,  197 

■ — ,  prone  jDosition  on  back 
essential   in,    197 

Epithelioma,    113 

- — ,  cell-nests  of,    113 

— ,  diagnosis  from  lupus  vul- 
garis,  223 

— ,  nature  and  growth  of,  113 

— ■    of  tongue,    186 

Epulis,  137,   192 

Erysipelas,  Si 

— ,  causal  micro-organism,  Si 

— ,  cellulo-cutaneous,  S2 

— ,  facial,  diagnosis  from 
ophthalmic  herpes,  82 

— ,  symptoms,  81,  82 

— ,  treatment,  general,  82  ; 

— •  — ,  local,  82 

Ethylene  dichloridc,  solution 
of  iodine  in,   14 

Exophthalmos  in  Graves's 
disease,  76 

Exostoses,  ivorj",  136 

Expectorant  for  use  in  acute 
laryngitis,    206,    207 

Exudation,  serous  and  plastic, 
in  inflammation,  19 

Eye,  diseases  of,  211 

Eye-ball,  excision  for  panoph- 
thalmitis,   218 

Eyes,  bandaging  forbidden  in 
muco-purulent  conjunc- 
tivitis, 212 


Face,   gummata   of  bones  of, 

— ■,   injuries  of,  162 

— ,  tuberculosis   of   bones   of, 

135 
— ,  tumours      of      bones      of, 

simple,  138 

,  malignant,  138 

Fainting,    see   Synco-pe 
False  joint  from  non-union  of 

fractures,    123 
Fauces,  spraving  in  erysipelas, 

83 

Females,  uncontrollable 
haemorrhage  in,  follow- 
ing teeth  extraction,  41 

- — ,  transmission  of  haemo- 
philia by,  104 

Ferric  chloride  as  styptic, 
40 

Fever,  accompanying  frac- 
tures, 121 

— ,  accompanying  inflamma- 
tion, 21,  22 

Fibrin  ferment,  in  haemo- 
philia, 40,    105 

Fibro-adenoma,  112 

Fibroma,  108 

— ,  hard,  loS 

— •    of  bone,  137 

— ,  soft,   108 

Fistula,  salivary,  205 

Fistulas,  23 

— ,  how  differing  from  sin- 
uses, 23 

Foot,  perforating  ulcer  of,  29, 
30 

Forceps,  dressing,  must  be 
rendered  aseptic  and 
antiseptic  before  use,   11 

-—  (Spencer  Wells)  in  control 
of  haemorrhage,  in 
tracheotomy,    178 

Foreign  bodies  in  air  passages, 
164 

,  cysts    due    to    presence 

of,  118 

— ■  —  in  air  passages,  extrac- 
tion, 164,   165 

—  — -    in  oesophagus,    166 

,  determination         of 

position  by  X-rays,   166 

Formamint  lozenges  in  catar- 
rhal   stomatitis,    168 

Fracture   dislocations,    141 

-of  shoulder-joint,    147 


232 


INDEX 


Fractures,  1 19-129 

— ,  age    and    sex    prevalence, 

120 
— ,  comminuted,    119 
— ,  compound,    119 

,  treatment,  122,  123 

— ,  diagnosis,  121 

,  of     dislocations    from, 

141 
— ,  exciting  cause,    120 
— ,  general  clinical  signs,  121 
— ,  greenstick,  119 
— ,  impacted,  119 
— ,  method  of  union,   119 
,  callus  formation  in, 

119,   120 
— ,  multiple,    119 
— ,  non-union,    123 
— ■  — ,  resulting  in  false   joint, 

123 
— -    of  hyoid  bone,  129 
— -    of  jaw,   upper,    126 
,  lower,  126-129 

—  of  lachrymal  bone,  125 

—  of  malar  bone,  125 

—  of  nasal  bones,   124 

—  of  skull,    123 
— ,  simple,    119 

- — ,  treatment,  121,  122 

-,  application    of    splints 

in,  122 

—  — ,  impaction  in,   122 

—  — -,  massage     and    passive 

movement  in,  122 

— ■  — ,  traction  and  manipula- 
tion in,  121,  122 

— ,  union,  causes  of  delay  in, 
120 

Frontal  sinus,  catarrh  of, 
acute,   203 

,  empyema    of,    chronic, 

203 

,  suppuration   in,    acute, 

203 

,  treatment,  opera- 
tive, 203 

—  ■ — ,  tumours  of,  203 
Fronto-nasal  process,   171 
Furunculosis,  35,  36 


Gangrene,  31-36 
—    (dry),  31 

,  curative      process 

ulceration   in,  33 


of 


Gangrene,    dry,    clinical    his- 
tory, 32 

—  — ,  diabetic,  32 

,  due  to  ergotism,  32 

— •  — ,  embolic,  32 

,  idiopathic     (Raynaud's 

disease),  32 
,  line  of  demarcation  in, 

33 
,  neuralgic  pam  at  com- 
mencement of,  33 

—  — ,  thrombotic,  32 

—  — ,  traumatic,  31 

• — ,  following      inflammation, 
21 

—  (hospital),  34 

—  (moist),   line  of   demarca- 

tioii  in,  33 

—  (septic),    acute    spreading 

traumatic,  34 

,  symptoms,  34 

■,  varieties  of,  34 

— ,  symptoms  and  signs,  32 
— ,  treatment,  33,  34 
— •  — ,  by  amputation,  33,  34 
Gargle    for    s^i^hilitic    throat 

symptoms,   95 
Gasserian    ganglion,   removal 

in  tic  douloureux,  64 
Gelsemium,     tincture     of,     in 

herpes  zoster,  69 

—  — ,  in  tic  douloureux,  64 
Germicides,    see   A7itiseJ)tics. 
Giemsa's    method      used     for 

staining  S^irocliceta  -pal- 

lida,  91 
Gingivitis,  188 
• — ,  treatment,  1S8 
Glands,  inguinal,  suppurating, 

in  gonorrhoea,  treatment, 

Glaucoma,  216 

—  and    iritis,    difference    be- 

tween, 217 
Gleet,  chronic,  in  gonorrhoea, 

89 
Glioma,  109 
Glossitis,     superficial,     acute, 

183 

—  — ,  chronic,    184 
Glottis,    scald    of,    treatment, 

47 
Glycerine        of        belladonna 

fomentation      in      acute 

lymphangitis,  70 
in  acute  neuritis,  62 


INDEX 


233 


Glycerine  of  belladonna 
fomentation  in  acute 
thyroiditis,   75 

Goitre,  75,  76 

—  (exophthalmic),    age    and 

sex  distribution,  76 
,  cardinal  signs  of,  76,  'jy 

—  — ,  treatment,   '/'] 

— -,  simple      parenchymatous, 

— ,  symptoms,  76 

•  — ,  treatment,  76 

Gold  wire  with  electric  cur- 
rent, introduction  into 
aneurism,  57 

Gonorrhoea,  88 

— ,  complications,   89 

— -,  diagnosis,  88 

■ — ,  incubation  period,  88 

— ,  local  manifestations  and 
symptoms,  88 

— ,  treatment,  88  ;  by  drugs, 
88;  by  serum,  89;  by 
urethral  injections,  89 

— ,  see  also  Arthritis,  Syno- 
vitis^ gonorrhoeal 

Gout,  diagnosis,   152 

— ,  treatment,   153 

Graves's  disease,  see  Goitre, 
(exophthalmic). 

Greenstick  fractures,  119 

Gumma  in  mouth,   170 

—  of  tertiary  syphilis,  94 
,  treatment,  95 

—  of  tongue,   185 
Gummata,    multiple  of   bone, 

135 
— ■    of  bones  of  face,  136 
Gums,  diseases  of,  188-193 
— ,  hypertrophy     of,     simple, 

190 
— ,  inflammation  of,  see  Gin- 
givitis 
Gunning  splint,  12S 
Gunshot  wounds,  44 

H^MATEMESIS,    54 

Haematoma,  2>7i  162 
Haematuria,  54 
Haemophilia,    104 

—  affecting  joints,   158 
— ,  causes  of,  104 

— J  coagulation  period  of 
blood  increased  in,  104 

— ,  internal  haemorrhages  in, 
104 


Haemophilia,  prevalence 
greatest  amongst  males, 
104 

— ,  prognosis,    104 

— ,  transmission  by  females, 
104 

— ,  treatment,    104,   105 

,  by  fibrin   ferment,   40 

Haemoptysis,  54 

Haemorrhage,    51-54 

• — ,  arrest  of,  in  wound,  treat- 
ment, 38-43 

—  (arterial),   41,    51 

— ■  ■ — ,  control  of,  41,  42 
— ■    (capillary),  51 

—  in  tracheotomy,  control  by 

Spencer   Wells'   forceps, 
.178 

—  (internal),  in  haemophilia, 

104 
— ,  profuse,  administration  of 

opium  after,  42 
,  injection  of  saline  solu- 
tion after,  42 

—  (recurrent  or  reactionary), 

51,  52 
— ■  — •  — ,  treatment,  52 

—  (secondary),  causes  of,  52 
— -  — ,  treatment,    52 

—  (uncontrollable),      follow- 

ing   teeth    extraction    in 
females,  41 
— ■  — ,  in      deeply     jaundiced 
patients,  41 

—  (venous),  51 
Hammamelis,  as  styptic,  40 
Hammond's  wire  splint,    12S 
Hare-lip,  171 

— ,  operation  for  described, 
172,  173 

Heart,  massage  of,  in  syn- 
cope, 53 

— ,  stimulation,  means  for  in 
syncope,    53 

Heart-failure  complicating 
diphtheria,   176 

Heat,  effect  on  bacteria.   5 

— ,  moist,  application  in  in- 
flammation, 24 

Hectic  fever,  49 

Hemithyroidectomy  in  ex- 
ophthalmic goitre,  yy 

— ■    in  simple  goitre,  76 

Herpes  in  tic  douloureux,  63 

—    labialis,  171 


234 


INDEX 


Herpes,  ophthalmic,  diagnosis 
from  facial  erj'sipelas, 
82 

—  zoster,  symptoms,  68,  69 

,  treatment,  6q 

Hip-joint,     dislocations,     14S- 

150 

—  —  (anterior),   148 
,    obturator,      clinical 

signs,   i4p 
,  pubic,  clinical  signs, 

150 

— ,  treatment,  150 

(posterior),   148 

,  clinical  signs,  i^g 

-•  — ■  — ,  treatment,  149 
Hospital    gangrene,    34 
Hutchinsonian  teeth,  97 
Hydatid  cysts,  1 17 
Hydrocele     in     secondary 

syphilis,  93 
Hydrogen    peroxide    solution, 

lavage    of    soft    chancre 

with,   91 
Hydrophobia,      diagnosis      of 

tetanus  from,  85 
Hygroma,  cystic,   71 
Hyoid  bone,  fractures  of,  129 

,  treatment,    129 

Hyperjemia,   19 

—  of  conjunctiva,  simple,  211 
— ,  reduction  in  inflammation, 

24 
Hypertrophy  of  gums,  simple, 

190 
Hyphomycetes,    5,    6 
Hypopyon  in  keratitis,  218 

IcHTHVOL    ointment,    applica- 
tion in  erysipelas,  82 
Immunity,  8 

—  (acc|uired),  8 
,  active,  9 

—  — ,  passive,  9 

—  (natural),  8 

,  agency     of     leucocytes 

in,  9 

,  cold-catching,  break- 
down of,  8 

—  ■  — ,      factors      tending      to 

lower,  9 
Infection,  definition,  7 
— ,  general,  8 
— ,  local,  8 


and 


and 


m 


Inflammation,  18-25 

— ,  accompanied  by  fever,  21. 

22 
Inflammation,    bacterial,     21, 

— ,  cardinal  signs  in,  18 
— ,  chronic,  21 

,  treatment,  24 

- — ,  clinical    signs,    local    and 

general,  21 
— ,  definition,  18 
— ,  following        burns 

scalds,  45 
— ,  methods    of    termination, 

20,  21 

—  of  internal  organs  follow- 

ing   burns    and     scalds, 

46 
— ,  phenomena  of,  18 
— ,  stages  in,  18-20 
— ,  treatment,  24 

,  general,  25 

Instruments,       boiling 

sterilization  of,   15 
Involucrum,  130 
Iodides,      administration 

S3'philis,  96 

-in  aneurism,  57 

Iodine,  application  to  patients 

before  operations,  advan- 
tages, 14,  15 
— ,  best  solution  for,  14 
■ — ■    liniment,     application     in 

erysipelas,  82 
— ,  tincture  of,  application  in 

chronic      lymphadenitis, 

29,  72 
lodism,    precautions    against, 

96 
— ,  treatment,  29 
Iodoform,  dusting  soft  chancre 

with,  91 

—  emulsion,     sterilized,     in- 

jection    in     tuberculous 

arthritis,  156 
lodolysin    in    simple    chronic 

synovitis,    154 
Ionization  in  chronic  neuritis, 

62 
Iritis,  215 
— ,  treatment,  216 

—  and   glaucoma,    difference 

between,  217 
Iron  and  arsenic  in  exopthal- 

mic  goitre,  "jj 
Iron    compounds    as    styptics, 

40 


INDEX 


235 


Iron  salts,  danger  as  styptics, 

40 
Ivory  exostoses,  136 

Jauxdicf:,    severe,    uncontrol- 
lable     haemorrhage      in 
patients  with,  41 
Jaw,  ankylosis  of,  160 
— ,  fibrocystic  disease   of,  see 

Odontome,  epithelial 
- —    (lower),  excision  in  recur- 
rent ankylosis,  160 

■^ ,  dislocations,    142 

,  bilateral,    142 

,  breaking    down    ad- 
hesions,  143 

— ,  clinical  signs,  142 

,  reduction,    143 

,  unilateral,    142 

,  fractures,      treatment 

by  splints,   128,   i2q 
- — ,  phosphorus     necrosis     of, 
prophylaxis     and     treat- 
ment,  IQO 
—    (upper),   fractures  of,    126 

,  — •  of  alveolar  process, 

126 

— -^  — •  of  body,  126 

— ,  treatment,   126 

,  osteomata  of,   1Q3 

Jaws,    actinomycosis   of,    loi, 

i8g 
— ,  bones  of,  diseases,  189 
— ,  carcinoma  of,  1Q3 
— ,  diseases  of,   188-193 
— ,  osteomvelitis     of,     acute, 

189 
- — ,  phosphorus,     necrosis    of, 

189 
' — ,  sarcoma  of,  193 
- — ,  spasmodic     closure,     160, 

see  also  Trismus 
— ,  syphilis  of,   189 
— ,  tuberculosis  of,  189 
Joints,    haemophilia   affecting, 

.  1.58  . 
— ,  injuries  of,  139-151 
— ,  neuropathic  affections,  159 
— ,  wounds  involving,    139 

Keith,   Prof.   A.,   on   acrome- 
galy, 78,  79 
Keloid,  222 
Keratitis,  217 
— ,  hypopyon  in,  218 
— ,  interstitial,   219 


Keratitis,  perforation  in,  218 
• — ,  ulcerative,  217 

,  treatment,  218 

Killian's  operation,  203 
KlclDS-Loefitler    bacillus,     175, 
176,     see     also     Bacillus 
di-phthcrix 
Knee-joint  dislocations,    150 
• — ,  inflammation,     in     gonor- 
rhoea, 89 
• — ,  internal  derangement,  151 
Kocher's  method  of  reduction 
of  dislocation  of  shoulder- 
joint,  147 
Koch-Weeks  bacillus,  211 
Krameria,  as  styptic,  40 

Lachrymal  bone,  fracture  of. 

Laryngitis,  acute,  206 
,  causes  of,   206 

—  — ,  treatment,  206 
— ,  chronic,  207 

— •  — ,   treatment,   207 
Laryngotomy    for    obstruction 

by  foreign  bodies,  165 
Larynx,  diseases  of,  206 
Leiter's   tubes,    application   of 

cold  by,  in  inflammation, 

Leontiasis  ossea,   193 
Leucocytes,  agency  in  natural 

immunity,  9 
— ,  behaviour  in  inflammation. 

Leukoplakia,  184 
Lightning,  burns  due  to,  47 
Lip,  syphilis  of,  172 
Lipoma,   108 
— ,  diagnosis      of      sebaceous 

cyst  from,   117 
■ — ,  diffuse,   109 
Lipomatosis    (diffuse  lipoma), 

109 
Lotio   plumbi,   application    in 

contusions,  38 

—  -    rubra  in  acute  ulcer,  28 
Lotion,  application  in  chronic 

catarrhal  rhinitis,  195 
Lotions  in  conjunctivitis,  212- 

214 
Lupus  vulgaris,  223 
,  apple-jelly  nodules  of, 

223 

,   diagnosis,    223 

from      epithelioma, 


236 


INDEX 


Lymphadenitis  (acute),  72 
,  treatment,  72 

—  (chronic),  72 
,  treatment,  72 

—  (tuberculous,  chronic),  'j'^ 
,  predisposing  causes, 

7?, 
, treatment,   t^ 

—  —  —  — ,  operative,  -j^,  74 
Lymphadenoma,  74,  no 

— ,  diagnosis,  74 
—    (tuberculous,        chronic), 
clinical     manifestations, 

— ,  treatment,  74 

Lymphangcioma,    71,    no 

■ — ,  capillary,  71 

— ,  cavernous,  71 

— ,  cystic,  71 

^,  treatment,  71 

Lymphangioplasty  in  elephan- 
tiasis,  71 

Lymphangitis  (acute),  70 

— -  — ,  treatment,  70 

— ,  chronic,   70 

— ,  syphilitic,  70 

— ,  tuberculous,  70 

Lymphatic  glands,  enlarge- 
ment in  secondary 
syphilis,  93 

Lymphatic  system,  diseases  of, 
70-74 

Lymphatics  (artificial)  forma- 
tion, 71 

Lymphosarcoma,  74 


MaceWEN's  acu-puncturc  in 
aneurism,  57 

Macrocheilia,  72,   171 

— ,  treatment,  72 

Macroglossia,  71 

— ,  treatment,  72 

Malar  bone,  fractures  of,  125 

,  regions       involved, 

125 

,  treatment,    125 

• ,  avoidance  of  sep- 
sis in,  125 

Males,  greatest  prevalence  of 
haemophilia  among,  104 

Malignant  pustule,  cS7  see 
also  Anthrax 

Mandible,  changes  in  acrome- 
galy, 79 


Martin,  Sidney,  F.R.S.,  de- 
finition of  inflammation, 
iS 

Massage  after  operations  on 
nerves,  62 

—  in    chronic    inflammation, 

•  -^  •  ■ 

—  m      neuritis,      acute      and 

chronic,  62 

—  and  passive  movements  in 

dislocations,  141 

of  shoulder-joint, 

146 

— -in  fractures,  122 

—  in   sprains   and 

strains,  139 

in  traumatic  ar- 
thritis,   153 

■  ■ — -in  trismus,  161 

Maxilla,  superior,  see  Jaw, 
upper 

Maxillary  sinus,  catarrhal  in- 
flammation of,  acute,  iQQ 

—  — ^5  suppuration   in,    acute, 

200 
— ,     puncture     through 

nose  in,  201 

,  transillumination,  200 

Melaena,  54 
Melanin,  in 
Melanuria,  in 
Mercury,      in 

aneurism. 


of 


treatment 

.  .57 
of  syphilis,  95 

,  administration       by 

mouth,  95 
by  intramuscular  injec- 
tions, 95 
— ■  -  -    by  inunction,  95 
— ,  perchloride  of,   not  to  be 
used    for    sterilizing    in- 
struments, 15 
Metabolism,  disturbance  of,  7 
Micro-organisms,  invasion  of 

body  by,  effects,  6 
— ,  pathogenic,  6 
Micros-poron  Audoiiini,   6 
Morphia,  in  herpes  zoster,  69 
Mouth,  carcinoma  of,  171 
— ,  congenital  defects  of,  171 
Mouth,  cysts  of,  170 
— ,  dermoid  cysts  of,    170 
— ,  gumma  in,  170 
— ,  syphilis  of,  170 
— ,  ulceration  of,  tuberculous, 
171 


INDEX 


237 


Mouth-wash  in  catarrhal 
stomatitis,  168 

—  in  gingivitis,  188 

Mouth-washes  during  mer- 
curial treatment  of 
syphilis,  95 

—  in       chronic       superficial 

glossitis,    184 
Mumps,  204 
Myeloma,    138 
Myoma,   ioq 
Myxoedcma,   75 
Myxoma,   loS 


N-EVUS,    simple   or   capillary, 

no 
— ,  venous,      no,      see      also 

A)igeionia,   cavernous 
Xasal  bones,  fracture,   124 
— ■  — •  — ,  treatment,    124,    125 
Naso-pharynx,      polypus     of, 

137 
Xeck,  diseases  of,  208-210 
— ,  injuries  of,   162 
— ,  wounds  of,    163 

—  — ,  complications,    163 
-,  shock  and  collapse  in, 

164 

■,  treatment,   164 

Necrosis  of  bone,   130,  133 

—  of  jaws  (phosphorus),   1S9 
Nerve,  facial  (seventhcranial), 

disease  of,  64 

^  affecting      lower 

motor  neuron,  65-67 

—  — ,  affecting     upper 

motor  neuron,  65-67 

•  —  - — ,  causes  of,  64 

— •  — ■ ,  prognosis,    67 

,  treatment,  67 

— ,  hypoglossal,  or  twelfth 
cranial,  paralysis  of,   68 

Nerve-anastomosis,  62 

Nerve-grafting,  61 

Nerves,  compression,  61 

— ,  diseases  of,  6i-6g 

— ,  division,  partial  or  com- 
plete, 61 

■ ,  treatment,    61 

— ,  injuries  of,  61,  62 

Nerves,  injuries  to,  in  disloca- 
tions of  shoulder-joint, 
147 

— ,  spinal,  disease  of,  68 


Neuralgia,      of     commencing 

dry  gangrene,  33 
—,  see   also    Tic   Douloureux 
Neuritis,   acute,   62 

—  — ,  treatment,  62 

— ,  chronic,   symptoms,   62 

,  treatment,   62 

— ,  facial,  alcoholic,  rare,  65 

— ,  rheumatic,  64 

Neurofibroma,    108 

— ,  false,   loS 

— ,  multiple,   108 

Neuroma,    108 

— ,  false,   108 

New  growths,  solid,    106-115 

Nodes,  syphilitic,  in  bone,  135 

Noma  vulvae,  35 

Nose  bleeding,  see  Efistaxis 

Nose,    bleeding-point    in    epi- 

staxis,  ig7 
— ,  in  diphtheria,   195 
— ,  diseases  of,   194 
— ,  foreign  bodies  in,  198 
— ,  polypus  of,   196 

Odontoma,  no,  190 
Odontome,  composite,  192 
— ,  epithelial,    191 
— ,  fibrous,   192 
— ,  follicular,    190 

,  compound,    191 

- — ,  radicular,    192 

Odontomes,    117 

CEsophagus,     foreign     bodies 

in,   166 
— ,  wounding  of  in  wounds  of 

neck,  164 
O'idiuin  alhicans^  6 

—  — ,  cause  of  thrush,  169 
Onychia,  syphilitic,  93 
Operations,   aseptic  and  anti- 
septic,   precautions    dur- 
ing,  12,   13 

,  precautions  during, 

by  iodine  method,   14 
— ,  assistants     at,     surgically 

clean  and  unclean,  both 

necessary,   16 
—,  surgical  cleanliness  at,  16 
— ,  dress  at,   16 
Ophthalmia  neonatorum,  212 
Ophthalmia       neonatorum, 

prophylaxis,   213 

,  treatment,   213 

Opium,    administration    after 

profuse  haemorrhage,  42 


238 


INDEX 


Opsonic  index  in  tuberculous 

arthritis,    156 
Oral      cavity,       inflammation 

affecting,     in     secondary 

syphilis,   03 

—  sepsis,        causing       osteo- 

arthritis,   157 
Orchitis,  late  complication  in 

secondary  syphilis,   93 
Orthoform,    dusting    with    in 

ulceration  of  tongue,  185 
Osteitis   (rarefactive),    133 
- — ■  — ,  abscess  in  later  stages, 

TOO 

— •  — ,  causes,    133 

—  — ,  combined    with    sclero- 

sis, 133 
Osteo-arthritis,    157 
• — ,   diagnosis,   158 
— ,  mono-articular,    157 

—  of  temporo-maxillary  artic- 

ulation,   160 
— ,  polyarticular,   158 
— ,  sources  of,   157 
Osteoma,   109,   136 
— ,  spongy,  136 

—  of  upper  jaw,   193 
Osteomyelitis   (acute),   131 

—  — ,  diagnosis,    132 
— •  —    of  jaws,  189 

,  sequestrum  in,  re- 
moval,  132 

,   streptococcal,   132 

— •  — ,  treatment,    132 

Otitis  media  complicating 
diphtheria,    176 

Ozaena,  196 


Palate,        perforations        of, 

acquired,   174 
— ,  tumours  of,   174 
— ,  ulcer  of,   174 
Palsy,  see  BelVs  -palsy 
Pannus,  trachomatous,   215 
Panophthalmitis,    218 
Papilloma,  112 
Paralysis    of    external    rectus 

muscle  of  eye,  65 

—  (diphtheritic),       following 

diphtheria,    17C 
— ,  facial,  64-67 
— ,  general,  of  insane,  94 
Paralysis        of        hypoglossal 

nerve,   68 

—  of  stapedius  muscle,  66 


Parasyphilitic  affections,  94 
Parotid  gland,  carcinoma  of, 

205 
— ,  sarcoma  of,  205 

—  tumour,   204 
Parotitis,  acute,   204 
— ,  chronic,   204 

— ,  epidemic,  204 

Passive  movements  and  mas- 
sage, see  Massage  and 
passive  movements 

Patella,  dislocations,  150 

Pemphigus  of  secondary 
syphilis,  93 

Periostitis,  sclerotic,  syphili- 
tic,   135. 

—  (traumatic,  acute),   131 

— ,  clinical    signs,    131 

,  treatment,    131 

Phagedaena,  35 
Pharyngitis,   acute,    180 

— ,  chronic,    180 

,  symptoms,   180 

,  treatment,  i%p 

Pharynx,  abscess  of,  180 
— -,  carcinoma  of,  180 
— ,  sarcoma  of,  180 
— ,  syphilis  of,   180 
— ,  wounding  of,    164 
Phenacetin    in    herpes    zoster, 

Phlebitis  (infective),  58 

— •  — ,  treatment,   59 

— ,   simple,  non-infective,   58 

— ,  thrombosis     accompanies, 

Phlegmasia  alba  dolens,  58 

— ,  clinical   signs,    58 

,  followedbypyaemia, 

59 

— • ,  treatment,   59 

"  Phossy  jaw,"  see  Jaws 
phosphorus    necrosis     of 

Picric  acid  dressing  for  burns 
and  scalds,  46 

Pigeon-breast  in  rickets,   102 

Piles,  59 

— ,  treatment,  60 

"  Pins  and  needles,"  sensation 
of,  61 

von  Pirquet's  test  in  tuber- 
culous arthritis,   156 

Pituitary  body,  abnormal  en- 
largement, connection 
with  acromegaly,   78,   79 

,  diseases  of,  78 


INDEX 


-'39 


Pneumococcus     infection      in 

ulcerative  stomatitis,  168 
— ,  virulent, presence inmouth 

without  infection,  7 
Polypus,  nasal,   106 
— ,  nasopharyngeal,    137 
Potassium      bicarbonate      and 

tincture    of    hyoscyamuc 

in  gonorrhoea,  88 
— •    chlorate        in        catarrhal 

stomatitis,   167 

—  iodide  in  syphilitic  ulcer, 

29 
— ■  — •    in  simple  goitre,  76 
Pott's  disease,  209 

—  — ,  clinical  signs,  209 

• ,  diagnosis,    210 

,  treatment,  210 

Protozoa,  6 
Psammoma,   115 
Ptosis,  219 

— ,  acquired,   219 

— ,  congenital,  219 

— ,  unilateral,  in  tic  doulour- 
eux, 63 

Pus,  22 

Pyaemia,  50 

— ,  clinical  signs,  50 

— ,  complicating  cancrum 

oris,  35 

—  may     follow     phlegmasia 

alba  dolens,  59 
Pyorrhoea  alveolaris,   189 
J  causing   osteo-arthritis, 

157 

Quinine,  in  erysipelas.  82 
Quinsy,  175 

Rachitis,  see  Rickets 

Radium,  treatment  by,  of  sar- 
coma,  112 

Ranula,   170 

Ray  fungus,  100 

Raynaud's   disease,   32 

Recklinghausen's  disease,   108 

Rectus  muscle  of  eye,  external, 
paralysis,  65 

Resolution  after  inflammation, 
20 

Rest,  in  inflammation,  24 

Retropharyngeal  abscess  com- 
plicating cervical  caries, 
210 

Revolver-shot  wounds,  44 


Rheumatism  (acute)  in  tem- 
poro-maxillary  articula- 
tion,   159 

—  —    rare    in    children,    132, 

Rhinitis,   194 

- -,  atrophic,  chronic,  196 
---  (catarrhal),  acute,  194 
- —  —  — ,  treatment,    194 

—  — ,  chronic,  195 
,  treatment,    195 

— ,  hypertrophic,  chronic,  196 

— ,  sicca,   196 

— ,  suppurative,  acute,  195 

Rickets,  102 

— ,  changes  in  bones  in,  102 

— ,  symptoms  and  complica- 
tions, 103 

— ,  treatment,  103 

Rickety  rosary,  J02 

Ringworm,  organisms  caus- 
ing, 6 

Rodent  ulcer,  222 

— ■  — ,  treatment,   222 

Rupia  of  secondary  syphilis, 
93 

Saline  infusion  in  tetanus,  86 

—  purges  in  gonorrhoea,  89 

—  solution     injection      after 

profuse  haemorrhage,   42 

Salivary  glands,  diseases  of, 
204 

Salvarsan  (606)  in  lymph- 
adenoma,    74 

— ■  — ,  in  syphilis,  96 

Sapraemia   (chronic),  49 

— ,  treatment,  49 

Saprophytes,  4 

Sarcinae,  3 

Sarcoma,   no 

— ,  alveolar,  in 

— ,  melanotic,   1 1 1 

— ,  mixed-celled,    in 

— ,  myeloid,    in 

— ,  nature  of,  1 10 

— •    of  bone,  central,  137 

—  — ,  myeloid,   137,   13S 

,  periosteal,    137 

,  secondary,   138 

—  of  jaws,   193 

— ■  of  parotid  gland,  205 

—  of  pharynx,    180 

—  of  thyroid  gland,  'j'i 
— ■  of  tongue,   187 

—  of  tonsils,   179 


240 


INDEX 


Sarcoma,   round-celled,    iii 

— ,  secondary,  74 

— ,  spindle-celled,    iii 

— ,  treatment,  112 

Scald  of  glottis,  47 

— ■  — ,  treatment,  47 

Scalds,  see  Burns  and  scalds 

Scalp,  injuries  of,   162 

,  complications,    163 

,  treatment,   162 

Scarlet     fever,     diagnosis     of 

acute  follicular  tonsillitis 

from,  175 
Schizomycetes,    see    Bacteria 
Scirrhus  cancer,   113 
Sclerosis  of  bone,  133 
— •  — ,  diffuse   syphilitic,    135 
Scott's  dressing,  153,  154 

—  —    in    chronic    inflamma- 

tion, 24 
Scurvy,  103 
— -,  clinical   signs,    103 

—  (infantile),  103 
— ,  treatment,  103 

Sepsis    following    burns    and 

scalds,  45 
— ,  prevention  in  treatment  of 

fracture   of  malar  bone, 

125 

—  retards    healing    of    frac- 

tures, 120 
— ,  secondary        haemorrhage 

following,  52 
Septicaemia,  49 
Sequestration   dermoids,    116 
Sequestrum,   130 

—  formation  in   acute  osteo- 

myelitis, removal,  132 
-in  tuberculosis  of  bone, 

^34  . 

Scrum       (antigonococcic)      in 
gonorrhoea,  89 

—  (antitetanic),    injection   in 

tetanus,  86 

—  treatment       and      passive 

acquired  immunity,  9,  10 

Sexual    organs,    rudimentary, 
cysts  connected  with,  117 
Shingles,  see  Her-pcs  zoster 
Shock,   52 

—  accompany  fractures,   121 

—  following       burns        and 

scalds,  46 
,  treatment,  46 

—  in  wounds  of  neck,  164 


Shock,  treatment,  53 
Shoulder  -  joint     dislocations, 

144-147 
,  clinical   signs  common 

to  all  forms,   144 

—  —    complications,    147 
,  compound,   147 

—  —     reduction,  145,  146 

— by        manipulation, 

145 
-by  traction,  146 

—  — ,  subclavicular,  144  ; 

clinical  signs,  145 

,  sub  -  coracoid,        144; 

clinical  signs,  144 
,  subglenoid,    144;  clini- 
cal signs,  145 
— -  — -,  sub-spinous,  144;  clini- 
cay  signs,  145 

—  fracture  -  dislocations     of, 

147 
Silk,   sterilized,   in   formation 
of    artificial   lymphatics, 

Silver,  nitrate  of,  application 
in  erysipelas,  82^ 

,  solid,  as  styptic,  40 

Singer's  nodes,  207 

Sinuses,  23 

— ,  how  differing  from  fistulas. 

23 

Skin,  carcinoma  of,  223 

— -^  diseases  of,  221 

— J  eruptions  of  secondary 
syphilis,  92,  93 

Skull,  fractures  of  base,  123 

— ■  ■ — ■  - — ,  regions  involved, 
123 

— ,  treatment,  only  ex- 
pectant,  124 

,  followed     by     cerebral 

concussion  or  compres- 
sion,  124 

,  fractures  of  vault,  123, 

124 

— ,  treatment,    124 

Snakes,  poisonous,  wounds 
due  to  bites  of,  44 

Sodium  iodide  in  osteo- 
arthritis,   158 

Sore  throat,  see  Tonsillitis^ 
catarrhal,   acute 

Spasm  or  tic,  facial,  67 

•  — ,     diagnosis,  68 

,  treatment,  68 


INDEX 


241 


Spencer  Wells  forceps,  con- 
trol of  haemorrhage  in 
tracheotomy  by,  178 

Spinal  caries,  209 

Spirilla,  3,  4 

SfirocJiwta  -pallida,  6 

,  causal    micro-organism 

of  syphilis,  6,  91 

■,  description,  91 

,  staining  of,  91 

SpirochjEte,  4 

Splint  (Hammond's  Wire),  128 

— '    (nasal,  Cobb's),   125 

—  (Tomes's),    128 

Splints,  application  in  treat- 
ment of  fractures,   122 

—  for  fractures  of  lower  jaw, 

128,  129 
Spore-formation,   in   bacteria. 

Sprains  and  strains,   139 
■,  diagnosis     of     disloca- 
tion from,    141 
,  diagnosis     iDy     X-rays, 

139 

,  treatment,    139 

Squint,  see  Strabismus 
Stomatitis,  aphthous,    168 

—  (catarrhal),  167 

,  causes,    167 

,  treatment,    167 

— ,  gangrenous,  169 
— ,  mercurial,   168 

—  (ulcerative),  168 

,  due    to    pneumococcus 

infection,   168 
Stapedius     muscle,     paralysis 

of,  66 
Staphylococcus,    invasion     of 

wounds  by,  11 

—  aureus  or  albus,  presence 

in  acute  osteo-myelitis, 
132 

Stasis,  period  of  in  inflamma- 
tion, 19 

Status  lymphaticus,  105 

,  thA'mus  gland  persis- 
tent in,  105 

Stenson's  duct,  wounds  of,  205 

Stings  on  tongue,  183 

Strabismus,  219 

— ,  concomitant,  220 

— ,  kinetic,  220 

— ,  paralytic,   220 

Streptococci,  2 

Streptococcus,  invasion  of 
wounds  by,   11 

16 


Streptococcus  erysipelatis,  81 

—  'pyogenes,  35 
Streptothrix,  6 

Strychnine     poisoning,     diag- 
nosis of  tetanus  from,  85 

Styptics,  39-43 

— ,  inducing  coagulation  of 
protein  in  blood,  39 

—  —    local      constriction      of 

blood-vessels,   39 

Submaxillary  gland,  diseases 
of,  205 

Sunlight,  effect  on  bacteria,  5 

Suppuration  in  frontal  sinus, 
acute,  203 

— •  in  maxillary  sinus,  acute, 
200 

— ,  production  of,   21 

Surgical  cleanliness  at  opera- 
tion, means  to  ensure,  16 

of  dressers,  13 

Syncope,  or  fainting,  53 

,  treatment,   53 

Synovitis  (acute),  152 

,  diagnosis,   152,   153 

—  (chronic),  simple.  154 
,  treatment,   154 

—  (gonorrhoeal),     treatment, 

.^53 

— ,  simple  traumatic  in  tem- 
poro-maxillary  articula- 
tion, rare,  159 

Syphilis,  91,  97 

— ,  cause  of  sclerosis  of  bone, 

133 

—  (congenital),  96,  97 
,  clinical  signs,  97 

—  — ,  disease  of  bone  in,  135, 

136 
— ,  micro-organism      causing, 
6,  91 

—  of  jaws,  189 

—  of  pharynx,   180 

—  of       temporo  -  maxillary 

joint,  rare,   160 

—  of  tongue,    185 
— •    of  tonsils,  179 

—  (primary),  92 

,  hard  chancre  of,  8,  92 

of,  diagnosis  from 

soft  chancre,  90 

—  (secondary),   8 

—  — ,  clinical  features  of,  92 

93  . 
,  disease  of  bone  in,  135 

—  (tertiary),  93,  94 


242 


INDEX 


Syphilis  (tertiary),  disease  of 
bone  in,  clinical  varie- 
ties, 135 

,  gumma  of,  q4 

— ,  treatment,  94-96 

,  general,  95 

,  by  iodides,  96 

■  — ,  by  mercury,  95 

,  by  salvarsan    (606) 

dioxydiamino-a  r  s  e  n  o- 
benzol,  96 

,  local,  94 

Syphilitic  arthritis,   157 

—  caries  of  bone,  135 

—  endarteritis,    55 

■ —    epiphysitis,    135 

—  lymphangitis,  70 

—  ulcer,  see  Ulcers,  syphilitic 
Syringomyelia,      Charcot's 

disease  in,  159 
— ,  complicatedbyperforating 
ulcer  of  foot,  29 

Tabes  Dorsalis,  94 

,  Charcot's     disease     in, 

159 

■,  complicated  by  per- 
forating ulcer  of  foot,  29 

Tachycardia  in  exophthalmic 
goitre,  -]-] 

Taenia  echinococcus  producing 
hydatid  cysts,    117 

Tannic  acid  as  styptic,  39,  40 

Taste,  loss  of,  in  facial  para- 
lysis, 66 

Teeth  affections  in  congeni- 
tal syphilis,  97 

—  extraction,       control       of 

haemorrhage     following, 
by  adrenalin,  39 

—  — ,  followed  by  secondary 

haemorrhage,   52 

,   haemorrhage  following, 

calcium  as  styptic  in,  41 

,  uncontrollable 

in  females,  41 

— ,  syphilitic,  or  Hutchin- 
sonian,  97 

Temperature,  optimum,  for 
bacterial  growth,   5 

Temporo-maxillary  articula- 
tion, diseases  of,  159 

—  joint,  changes  in  acrome- 

galy, 79 
Teno-synovitis,  with  crepitus, 
diagnosis  from  fracture, 
121 


Teratoma,  115 

Tetanus,  cephalic,  85 

— ,  chronic,  85 

— -,  clinical  signs,  84 

— -,  diagnosis,    85 

— -  —    from  hydrophobia,  85 

from  strychnine  poison- 
ing,  85 

from  tetany,  85 

from  trismus,  85 

— ,  micro-organism  of,  83 

— ,  muscular  spasms  of,  84 

— ,  toxin  of,  mode  of  action, 
84 

— ,  treatment,  85,  86 

by     antitetanic     serum, 

86 

by      drugs      to      check 

spasms,  86 

Tetany,  diagnosis  of  tetanus 
from,   85 

Tetracocci,  3 

Thrombosis,  58 

—  accompanies  phlebitis,    58 
Thrush,  169 

— ,  complicating  rickets,  103 

— ,  micro-organism  causing, 
6,  169 

Thumb  (first  phalanx),  dis- 
locations,  148 

,  treatment,   148 

Thymus  gland,  persistent  in 
status  lymphaticus,    105 

Thyroid   gland,    adenoma   of, 

77 
— •  — ,  cancer  of,  yy,  78 

— ,  treatment,  78 

,  diseases  of,  75 

—  — ,  enlargement  as  whole, 

75 

in    exophthalmic 

goitre,  76,  77 

,  sarcoma  of,   78 

,  tumours  in,  77 

Thyroiditis,  acute,  75 

,  treatment,  75 

Tic  douloureux,  63 

—  — ,  symptoms,   63 
— •  — ,  treatment,  64 
Tissue-repair  after  inflamma- 
tion, 21 

Tomes's  sxjlint,   128 

Tongue,  actinomycosis  of,  187 

— ,  burns,   scalds,   and   stings 

of,   183 
— ,  diseases  of,   182-187 
— ,  epithelioma  of.    186 


INDEX 


243 


Tongue,  gumma  of,   185 

— ,  inflammation     of,     acute, 

183 
— ,  sarcoma  of,  1S7 
— ,  syphilis  of,   185 
— ,  ulcer  of,  185 
,  differential     diagnosis, 

187 

,  simple  traumatic,  185 

—  ■ — ,  tuberculous,    186 
— ,  wounds  of,  182 
Tongue-tie,  182 
Tonsillitis,    catarrhal,    acute, 

175 

— ,  follicular,  acute,  175 

•  — ,  diagnosis  from  scar- 
let fever,  175 

Tonsils,  carcinoma  of,  179 

— ,  diseases  of,  175 

— ,  enlargement  of,  chronic, 
179 

— ,  enucleation,    179 

— ,  removal  by  guillotine,  179 

— ,  sarcoma  of,  179 

— ,  syphilis  of,   179 

Tooth,  extraction  in  chronic 
antral  empyema  of  den- 
tal origin,  201 

,  resulting     cavity 

must  be  closed,  202 

Torticollis,  208 

— ,  acquired,  208 

— ,  congenital,  208 

— ,  paralytic,  209 

Toxins,  6 

— ,  extracellular,  6 

— ,  intracellular,  6 

Tracheotomy  in  acute  laryn- 
_  gitis,  207 

—  in   diphtheria,   high,    low, 

and    median    operations 
described,  177-179 
— ,  for  obstruction  by  foreign 
bodies,   165 

—  in  wounds  of  neck,  164 
Trachoma,  214 

— ,  treatment,  215 

Transillumination  of  maxil- 
lary sinus,  200 

Tremor,  fine  in  exophthalmic 
goitre,  77 

Trichophyton,  6 

Trismus,   160 

—  complicating  acute   osteo- 

myelitis of  jaw,  189 
— ,  diagnosis  of  tetanus  from, 
85 


irritative 


Trismus,        local 

causes,   160 
— ,  treatment,   161 
Tubercles  (miliary),  98,  99 
Tuberculin,       injections       in 

chronic      lymphadenitis, 

!?> 
Tuberculosis,  97-Q9 
— ,  bacillus  of,  97,  98 
— ,  caseation  in,  99 
— ,  frecjuent    cause    of    rare- 

factive  osteitis,  133 
— ,  general  symptoms,  99  _ 
-—    of  bone,  clinical  varieties, 

134,  135 

,  diagnosis,  134 

,  sequestra   in,    134 

— .  — ,  treatment,   134,   135 

—  of  cervical  vertebrae.  209 

—  of  jaws,  189 

^,  treatment,   general,   99 
Tuberculous   arteritis,    56 

—  arthritis,    154 

—  disease  of  temporo-maxil- 

lary  joint,  rare,  160 
— •    lymphangitis,  70 
Tubulo-dermoids,   116 
Tumour,      varying     uses      of 

term,   106 
Tumours,    connective 

malignant,   no 

.  — ,  simple,    108- 

— ,  epithelial,  simple, 

—  of   antrum,   202 

—  of  bones  of  face,   simple, 

138 
,  malignant,    138 

—  of     cartilage     and     bone, 

simple,   136 
,  malignant,    137 

—  of  frontal  sinus,  203 

—  of  palate,  174 
— ,  parotid,   204 

—  •    (solid),  simple  and  malig- 

nant, differences  between, 
107 


Ulcer  of  mouth,  tuberculous, 

171 

—  of  palate,  174 

—  of  tongue,  185 

,  differential     diagnosis, 

1 87 
,  simple  traumatic,   185 

,  tuberculous,    186 


tissue, 


•no 
112 


244 


INDEX 


Ulcer,    perforating     of     foot, 

29,  30 

— ,  complicating  dis- 
eases of  central  nervous 
system,  29 

— ,  rodent,  see  Rodent  ulcer 

Ulceration,   26-30 

— ,  curative  process  in  dry 
gangrene,  33 

— ,  production  of,  21 

Ulcers,   callous,   27 

^,  healing,  zones  surround- 
ing, 27 

— ,  irritable,   27 

,  treatment,  29 

—  (simple),   injuries  produc- 

ing, 27 

,  three  stages  of,  26,  27 

■  ,  acute,    treatment,    27, 

28 
,  chroni  c.      eczema 

around,  treatment,  29 

. ,  treatment    28 

bv   Unna's   method, 

28 
— ,  syphilitic,  treatment,  29 
— ,  trophic,  29,  30 
— •  — ,  treatment,  30 
— ,  varicose,  27 

,  treatment,   28 

Unna's    method    in    treatment 

of  chronic  ulcer,  28 

—  paste,        application       in 

chronic  ulcer.   28 
Urethra,    injections    into,    in 

gonorrhoea,  89 
— 5  stricture  of,  complicating 

gonorrhoea,  89 

Vaccination,  and  active  ac- 
quired immunity,  10 

Vaccine-treatment  of  carbun- 
cles and  boils,  36 

Vaccines  in  bacterial  infec- 
tions, 25 

Varicocele,  59,  60 

Varicose  veins,  59 

,  removal      in      chronic 

ulcer,  28 

,  treatment,  59,  60 

Varix,  aneurismal,  57 

Veins,  diseases  of,  55-60 

Vertebrae  (cervical),  tubercu- 
losis of,  209,  see  also 
Potfs   disease 

Vibrio,  4 


Vulva,  see  Noma  vulvae 

Warts,  221 

White    leg,     see    Phlegynasia 

alba  dolens 
W^hitehead's  operation,  60 
Wisdom   tooth,    extraction   in 

trismus,   161 
,  maleruption     as     local 

cause  of  trismus,   160 
Women,     greater    prevalence 

of     exophthalmic    goitre 

among,   76 
Wool-sorter's       disease,       see 

Anthracseviia 
Wounds,  37-50 
— ,  complications,  49,  50,  see 

also  Py3ej7iia,  Sa^raeJiiia, 

Sef>ticxmia 
— ,  healing       of,       by      first, 

second,  and  third  inten- 
tion, 47,  48 

—  (incised),  38 

—  — ,  cleansing  of,  42 
,  closure  of,  42 

,  septic,  drainage  of,  43 

,  treatment,  39-43 

■  — ,  constitutional,    42 

by  styptics,   39-43 

— ,  invasion  by  micro-organ- 
isms, II 

—  involving  joints,  139 

—  (lacerated   and   contused), 

treatment,  43 
— ■    (punctured),  43 

,  treatment,  43 

Wrist,   dislocations,    148 
Wryneck,   see   Torticollis 

X-RAYS,  diagnosis  bv^  of  dis- 
location   of    ankle-joint, 

151 

,  of  fractures,   121 

,  of  osteoarthritis,   158 

—  — ,  of  sarcoma    of    bone, 

137 

—  — ,  of  sprains  and  strains, 

^39. 

— ,  position  of  foreign  bodies 
in  oesophagus  determined 
by,   166 

— ,  treatment  by,  of  inoper- 
able cancer,  114 

— •  — ,  of  rodent  ulcer,  222 

,  of  sarcoma,  112 

Yeasts,  5 


John  Bale,  Sons  &   Daniei.sson,  Ltd.,  London,  W. 


COLUMBIA   UNIVERSITY   LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  library  rules  or  by  special  arrangement  with 
the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

-     ' 

i 

C28(B46)M2B 

i 

iiiimtm 

2002189291 


RD31 
Underwood 


Un2 


\KmZ 


